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CLINICAL    TALKS 

ON 

MINOR    SURGERY 


JAMES   G.   MUMFORD 


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CLINICAL    TALKS 


ON 


Minor  Surgery 


By 

JAMES    G.    MUMFORD,    M.D. 

Assistant  Visiting  Surgeon  to  the  Massachusetts 

General  Hospital,  and  Instructor  in  Surgery, 

Harvard  University  Medical  School. 


BOSTON 

INCORPORATED 

27  AND   29   BrOMFIELD    STREET 


Copyright,  1903 
By  James  G.  Mumford,  M.D. 


^fje  JFort  l^tll  press 

SAMUEL    USHER 

176  TO    184  HIGH   STREET 

BOSTON,  MASS. 


TO 

Maurice  Howe  Richardson,  M.D. 

In  recognition  of  eighteen  years  of  instruction  in  good  surgery, 
this  little  book  is  cordially  inscribed  by 

The  Writer 


NOTE 

This  series  of  brief  talks  is  the  outcome  of  an  inti- 
mate dealing  as  a  teacher  with  medical  students  for 
some  ten  years,  and  a  realization  of  certain  of  their 
needs.  I  have  treated  here  of  homely,  commonplace 
subjects.  Such  subjects  find  Httle  place  in  the  text- 
books and  lend  themselves  but  feebly  to  brilliancy  of 
demonstration. 

The  cases  described  and  the  printed  words  are 
reproductions  of  actual  experience. 

J.  G.  M. 

29  Commonwealth  Avenue, 
Boston,  May,  1903. 


CONTENTS 


Lecture  I.  The  Examination  and  Study  of  Cases 
Lecture  IL  Incised  Wounds 
Lecture  in .  Simple  Fractures 
Lecture  IV.  Lacerated  Wounds 
Lecture  V.  Compound  Fractures 


Lecture  VI.  Granulating     Wounds     and 
Ulcers  ..... 


Lecture  VII.  Felon,    Whitlow,  Paronycl 
Abscess 


Lecture  VIII.  Boils,  Carbuncles 

Lecture  IX.  Bunions,  Ingrowing  Nails,  Corns,  and 
Warts 


Lecture  X.  Massage 


Varicose 


ia,  Palmar 


I 

27 
36 

45 

56 

^1 
81 

93 
104 


Clinical  Talks  on  Minor  Surgery 


LECTURE    I 

THE    EXAMINATION    AND    STUDY    OP    CASES 

Gentlemen:  About  twelve  years  ago,  some  one 
coined  the  phrase  "antiseptic  conscience."  I 
think  it  was  Dr.  Kelly  of  Baltimore.  That 
phrase  and  the  thought  it  contains  were  once 
essential,  because  twelve  years  ago  most  of  the 
men  who  were  doing  the  surgery  of  the  world 
belonged  to  the  generation  which  in  its  youth 
knew  the  old  sepsis.  To  them  the  principles 
and  practice  of  antiseptic  surgery  came  halt- 
ingly and  often  imperfectly.  They  had  indeed 
need  to  cultivate  the  antiseptic  conscience: 
but  they  had  conscience  for  many  other  things, 
—  great  principles  underlying  good  surgery, 
principles  as  important  to-day  as  ever  they 
were.  One  is  impressed  at  times  with  the  con- 
viction   that    many    of    those     sound,    ancient 


2  CLINICAL   TALKS 

principles  latterly  are  being  pushed  back  into 
a  very  subordinate  position. 

To-day  a  majority  of  the  surgeons  in  active 
practice-  have  grown  up  with  the  antiseptic 
idea.  In  the  course  of  their  development,  the 
antiseptic  conscience  has  become  part  of  their 
being.  That  intangible  thing  which  we  call 
surgical  instinct  includes  and  partakes  of  that 
same  conscience.  There  is  no  danger  of  any 
man  who  has  received  his  training  in  the  past 
twenty  years  going  far  astray,  with  that  cqji- 
science  to  prompt  him.  Every  source  of  surgi- 
cal infection  has  been  so  thoroughly  and  univer- 
sally studied  that,  with  one  or  two  exceptions 
which  I  must  speak  of  later,  our  technique  is 
now  perfect,  or  as  near  perfection  as  it  is  likely 
to  become. 

But  there  are  those  other  principles  which 
were  so  important  to  the  former  generations. 
Are  you  students  of  to-day  aware  of  them?  Is 
it  not  a  fact  that  you  have  come  to  look  upon 
asepsis  as  the  one  thing  needful,  and  to  feel 
that,  asepsis  being  accomplished,  there  is  noth- 
ing more  to  be  done?  Are  you  to  be  as  good 
clinicians  as  were  your  surgical  forebears? 
That  is  a  question  which  your  teachers  often 
ask  themselves;  over  which  they  hesitate  in 
the    answer. 

If  I  name  some  of  those  general  principles  to 
which  I  refer  they  seem  commonplace  enough, 


ON   MINOR   SURGERY-  3 

and  most  of  you  will  say,  perhaps,  that  you 
have  them  always  in  mind;  but  such  is  not 
by  any  means  the  conclusion  of  observers 
who  watch  the  detail  of  work  in  our  great 
hospitals. 

The  most  important  lesson  which  a  surgeon 
has  to  learn  is  to  estimate  the  patient's  general 
condition.  I  put  that,  as  essentially  above 
any  question  of  therapeutics.  That  matter 
'of  the  general  condition  is  a  very  large  part  of 
diagnosis.  You  have  various  routine  questions 
which  you  ask  in  a  perfunctory  fashion:  the 
patient's  age,  birthplace,  residence,  occupa- 
tion, family  history  and  previous  condition  of 
health,  and  in  some  sort  you  learn  the  answers, 
—  but  those  answers  are  not  idle  babble ;  they 
have  a  very  real  bearing  on  the  matter  in  hand. 
Here,  in  this  surgical  clinic,  you  are  altogether 
too  prone  to  assume  that  every  case  you  see  is 
an  operative  one  pure  and  simple,  and  you  look 
no  further.  Gentlemen,  I  am  forced  to  admit 
and  I  admit  it  with  chagrin,  that  the  fault  lies 
largely  with  us,  your  surgical  teachers;  it  is 
one  of  the  deplorable  results  of  specialism  gone 
mad.  In  the  old  days,  it  was  required  of  the 
surgeon  that  he  have  a  good  practical  working 
knowledge  of  general  medicine.  Operations 
were  a  last  resort;  John  Hunter  and  List  on  told 
their  classes  that  the  knife  was  an  opprobrium, 
and  should  be  used  only  when  all  other  means 


4  CLINICAL   TALKS 

failed.  Of  course  that  extreme  view  has  long 
ceased  to  prevail;  —  modified,  first,  by  the  in- 
troduction of  anaesthetics  and  later  by  the 
development  of  asepsis.  Indeed  for  long  the 
pendulum  was  swinging  the  other  way,  when 
the  knife  was  deemed  the  only  reliable  meas- 
ure. Now,  again,  thanks  to  increased  knowl- 
edge, we  are  appreciating  that  there  are  other 
resources. 

Every  one  of  those  data  which  the  clinical 
clerk  takes  down  by  rote  may  be  of  the  greatest 
importance.  Age  may  rule  out  many  things, 
such  as  cancer,  arteriosclerosis  and  the  like;  the 
place  of  birth  and  the  race  may  suggest  tuber- 
culosis or  malaria,  as  may  the  residence.  The 
other  day  I  saw  a  case  of  anthrax  of  which  the 
diagnosis  w^as  rendered  probable  by  the  patient's 
surroundings  ;  there  are  numerous  occupation 
diseases,  —  lead-poisoning  and  "housemaid's- 
knee  "  will  at  once  occur  to  you.  That  matter 
of  family  history  or  hereditary  tendency  is  im- 
portant, in  spite  of  the  new  light  we  are  con- 
stantly getting  on  the  whole  question  of  eti- 
ology ;  and  especially  the  patient's  previous 
condition  of   health   is   to  be  studied. 

Here  is  a  patient  who  illustrates  in  his  own 
person  many  of  the  points  we  are  considering. 
You  see  he  is  a  young  man.  His  age  is  twenty- 
three.  He  is  of  American  parentage  and  of 
vigorous  stock.     He  was  born,  reared,  and  now 


ON   MINOR   SURGERY  5 

works  in  a  neighboring  town,  which  has  been 
notorious  for  its  unwholesome  location,  — 
being  low-lying,  ill  drained,  and  inadequately 
supplied  with  water.  The  young  fellow  is 
assistant  to  a  sewer  contractor,  and  spent  most 
of  last  summer  overseeing  a  gang  of  men 
engaged  in  laying  drains.  In  September  he 
became  ill  with  typhoid  fever,  as  appears  from 
his  physician's  statement  and  the  story  he  him- 
self tells.  Typhoid  was  epidemic  in  his  towm. 
Recovering,  after  an  illness  of  some  two  months, 
he  returned  to  work.  After  an  interval  of  six 
months  —  that  is  to  say,  two  or  three  days  ago, 
—  he  was  seized  with  acute  pain  in  the  region 
of  the  right  shoulder.  The  pain  increased,  and 
is  now  very  severe,  —  of  a  boring,  throbbing, 
agonizing  character.  You  see  for  yourselves 
that  the  patient  looks  like  a  sick  man.  He  is 
flushed,  with  a  coated  tongue,  the  bowels  are 
constipated,  the  urine  is  scanty  and  high  col- 
ored. The  man  supports  his  arm  in  his  hand; 
he  favors  it,  as  we  say,  and  is  evidently  in  great 
suffering.  On  examining  him  you  find  his 
pulse  to  be  bounding  and  rapid,  with  a  rate  of 
116,  and  a  blood  pressure  recorded  as  190  by 
the  Riva-Rocci  apparatus. 

When  you  come  to  handle  the  arm,  you  find 
some  slight  swelling  and  a  sense  of  bogginess 
about  the  shoulder  joint;  but  the  joint  itself 
is   not   especially   tender   on   pressure   and    the 


6  CLINICAL    TALKS 

patient  seems  to  refer  his  pain  rather  to  the 
head  of  the  humerus. 

Here  is  a  very  definite  picture,  gentlemen, 
On  the  history  alone  you  should  be  able  to  make 
a  correct  diagnosis.  The  man  is  obviously  the 
victim  of  an  acute'  infectious  process.  He  has 
been  for  long  exposed  to  unsanitary  conditions, 
and  he  has  recently  had  typhoid  fever.  My 
assistant  has  just  now  found  the  leucocytosis 
in  his  case  to  be  40,000,  and  the  temperature 
io4°F. 

What  are  we  to  conclude  from  this  collection 
of  signs  and  symptoms?  There  are  but  two 
processes  which  suggest  themselves  at  once  — 
an  acute  articular  rheumatism  and  an  acute 
osteomyelitis.  To  distinguish  between  these 
two  conditions  is  of  the  utmost  importance. 
In  the  two  diseases  the  signs  and  symptoms 
are  in  very  many  respects  identical;  but  we 
have  two  points  as  guides:  the  bone  rather 
than  the  joint  is  the  seat  of  pain,  and  the  patient 
has  recently  had  typhoid  fever.  We  know 
that  acute  infectious  diseases  are  frequent  pre- 
cursors of  osteomyelitis,  and  we  are  justified 
in  concluding  that  we  are  dealing  here  with 
that  process.  A  correct  decision  is  urgent. 
The  patient  will  be  admitted  to  the  hospital 
at  once,  the  shaft  of  his  humerus  will  be  opened 
and  drained,  and  he  will  doubtless  recover  with 
a  useful  arm.     A  few  days'  or  even  hours'  delay 


*     ON    MINOR   SURGERY  7 

might  mean  for  him  a  systemiic  infection,  sep- 
ticasmia,  and  death. 

To  take  up  the  thread  of  our  main  topic 
again;  there  is  that  indefinable  thing  we  call 
the  patient's  General  Condition.  Believe  me, 
you  cannot  too  soon  begin  to  bear  that  thought 
constantly  in  mind.  Old  Sir  Benjamin  Brodie 
used  to  say  that  he  could  often  make  a  diag- 
nosis by  the  smell  of  a  patient's  bedroom.  It 
is  unnecessary  for  us  to  know  such  shrewd 
tricks  as  that,  but  you  must  learn  to  put  all 
your  senses  into  action.  You  come  here  to 
this  clinic,  fresh  from  your  laboratory  studies. 
Hitherto  you  have  learned  only  the  uses  of  the 
sense  of  sight,  now  you  must  cultivate  your 
hearing,  touch,  and  even  smell,  like  old  Sir 
Benjamin;  and  you  must  come  gradually  to 
appreciate  that  nebulous  aura  of  physical  condi- 
tion which  every  man,  sick  or  well,  carries  with 
him.  When  to  these  things  you  add  those 
instruments  of  precision,  the  uses  of  which  you 
are  learning,  there  will  be  an  accuracy  and 
finality  to  your  decisions  which  were  impossible 
for  the  ancient  men. 

You  will  conclude  from  what  I  have  said 
that  a  competent  surgeon  must  be  a  very  thor- 
oughly-equipped all-round  man.  Exactly  that 
is  my  meaning.  You  must  study  your  general 
medicine  as  well  as  your  surgery,  and  you  must 
follow  carefully  both  sets  of  clinics.     There  was 


8  CLINICAL  TALKS 

a  time,  fifty  years  ago  and  less,  when  all  sur- 
geons were  general  practitioners.  Then  with 
the  development  of  specialties  came  a  natural 
and  proper  narrowing  of  the  surgeon's  field. 
For  years  we  devised  new  operations,  we  at- 
tacked organs  previously  regarded  as  inaccessi- 
ble, we  learned  and  perfected  a  new  practice 
and  a  new  technique.  It  has  come  about  with 
this  development  of  our  branch  of  the  art  of 
medicine,  that  many  diseases  as  well  as  organs 
have  become  the  surgeon's  own,  his  own  in  part 
at  least,  —  diseases  and  organs  with  which  he 
never  thought  to  tamper  a  few  years  ago.  So 
again  it  is  becoming  apparent  that  he  must  be 
familiar  with  a  great  variety  of  processes  which, 
a  few  years  ago,  concerned  him  little  if  at  all. 
In  that  second  stage  of  the  surgeon's  develop- 
ment, he  was  often  little  more  than  a  thorough 
anatomist  and  a  clever  handicraftsman.  We 
have  outgrown  that  stage.  We  now  realize 
that  the  surgeon  must  know  and  be  ready  to 
apply  the  principles  of  physiology,  chemistry, 
pathology,  and  bacteriology  as  well  as  those  of 
anatomy  and  physics.  He  deals  with  almost 
every  known  disease  and  with  every  organ  of 
the  body.  He  must  be  familiar  with  the  struc- 
ture and  function  of  those  organs,  the  nature 
of  their  disease  processes  and  the  appropriate 
methods  of  treatment,  if  he  is  to  put  to  their 
best  and  proper  uses  the  therapeutic  measures 


ON   MINOR  SURGERY  9 

with  which  he  is  especially  equipped.  He 
must  not  stand  idly  by  until  his  medical  con- 
frere says  "cut."  He  must  cut  when  the  time 
comes  of  course,  but  must  use  his  now  matured 
judgment  to  sustain  the  advice  of  his  colleague. 

Before  now,  following  the  old  blind  method, 
the  chest  has  been  opened  for  empyema,  when 
no  pus  was  there;  the  appendix  has  been  re- 
moved when  typhoid  fever  was  the  cause  of  the 
symptoms,  and  the  gall  bladder  has  been  opened 
for  the  cure  of  lumbricoid  worms.  I  have  even 
known  a  colleague  to  scoff  at  a  surgeon  who 
used  a  stethoscope,  and  to  look  upon  a  micro- 
scope as  an  instrument  outside  of  his  ken. 

In  all  this,  do  not  misunderstand  me.  A 
surgeon's  duty  is  the  treatment  of  disease  by 
proper  and  recognized  surgical  measures;  but 
he  should  have  a  sound  knowledge  of  all  disease 
as  well,  recognizing  his  own  limitations;  and 
while  his  medical  colleague  is  at  work  with'  his 
proper  investigations  and  remedies,  the  surgeon 
should  stand  by,  waiting  to  be  called  upon  for 
the  employment  of  his  own  peculiar  skill. 

Given  then  the  particular  case,  such  as  that 
of  the  man  with  osteomyelitis:  You  have 
looked  the  ground  over,  have  ascertained  the 
gravity  of  the  general  condition,  and  now  turn 
your  attention  to  the  special  lesion  under  con- 
sideration. That  lesion  is  in  the  arm  near  the 
shoulder  joint;  and  without  further  doubt  you 


lo  CLINICAL  TALKS 

make  your  diagnosis  and  recommend  appropri- 
ate treatment.  But  take  this  other  patient 
whom  I  show  you  as  a  foil  to  his  fellow.  He, 
too,  is  a  young  man,  —  not  more  than  thirty- 
five;  his  previous  condition  of  health  is  unim- 
portant, and  he,  too,  has  a  disease  near  the  shoul- 
der joint.  It  is  in  the  nature  of  a  swelling  or 
tumor,  and  he  has  had  it  for  some  fifteen  years. 
It  is  a  chronic  process,  therefore. 

When  you  see  a  swelling  there  are  two  ques- 
tions which  should  suggest  themselves  to  you 
at  once :  Is  this  an  inflammatory  process  or  is*  it 
a  neoplasm?  For  the  purposes  of  practical 
exclusion  you  run  over  rapidly  in  your  minds 
the  old  formula  which  applies  to  acute  inflam- 
mations —  Is  there  pain,  heat,  redness,  swell- 
ing, and  impairment  of  function?  In  this  case 
all  of  these  are  absent  save  swelling;  moreover, 
this  is  a  chronic  process.  Then  you  call  up 
your  other  familiar  formula  which  applies  to  a 
swelling  —  What  is  its  exact  location,  size,  shape, 
color,  consistency?  You  must  have  these  two 
formulae  always  in  mind;  always  on  your 
tongue's  tip,  and  be  ready  with  your  answers. 
This  swelling  has  none  of  the  characteristics  of 
inflammation  and  the  patient's  general  condi- 
tion is  excellent.  Therefore  it  is  probably  a 
neoplasm  and  of  a  benign  type.  You  say  it  is 
situated  just  below  the  acromion  process  over 
the  middle  of  the  deltoid  muscle.     It  is  about 


ON  MINOR  SURGERY  n 

the  size  of  a  small  orange;  it  is  spherical  and 
uniform  in  outline;  its  color  does  not  differ 
from  that  of  the  surrounding  skin;  it  is  soft, 
rather  gelatinous  to  the  touch,  but  it  does  not 
distinctly  fluctuate.  It  is  subcutaneous,  mov- 
able, not  adherent  to  the  skin,  and  the  adjacent 
glands  show  no  metastasis. 

Observe  carefully  the  method  of  approach- 
ing your  patient  and  handling  the  little  mass. 
See  that  he  sits  or  stands  at  ease  before  you, 
with  a  good  strong  light  upon  him  while  your 
own  back  is  turned  to  the  window.  Gain  his 
confidence  by  assuring  him  that  you  do  not 
expect  to  hurt  him.  He  will  then  sit  relaxed 
and  will  not  shrink  or  grow  tense  at  your  touch, 
—  an  important  desideratum.  Now  pass  your 
extended  palm  gently  over  the  tumor,  once 
or  twice.  In  that  way  you  will  gain  a 
great  deal  of  information,  and  if  the  parts  are 
sensitive,  you  will  give  no  pain.  The  tactus 
eruditus  does  not  belong  to  the  heavy-handed 
surgeon.  I  cannot  too  strongly  urge  upon  you 
the  great  advantage  and  importance  of  gentle- 
ness. Your  patient  will  recognize  it  at  once. 
He  knows  when  he  is  being  handled  by  a  man 
who  knows  his  business.  The  reputation  of 
being  a  rough  or  brutal  surgeon  helps  no  one. 

You  will  see  the  thoughtless,  inexpert  man 
plunge  at  a  painful,  sensitive  region  as  though 
he  were  kneading  dough.      You  can  tell  the 


12  CLINICAL   TALKS 

neophyte  at  once  by  his  roughness.  The  gentle 
outspread  palm  and  fingers  of  the  examiner 
are  extremely  sensitive  to  tactile  impressions 
and  can  be  educated  to  a  rare  facility.  It  is 
seldom  necessary  to  prod  and  poke  with  the 
finger  tips. 

Passing  my  hand  over  this  tumor  I  readily 
define  its  outline,  its  extent,  its  density,  its 
mobility,  and  I  note  the  absence  of  sensitive- 
ness. Now  if  I  choose,  I  can  pick  it  up  in  my 
finger-tips  and  determine,  if  necessary,  its  lack 
of  fluctuation  and  the  depth  of  its  attachments. 

That  is  the  whole  story.  You  have  the  list 
of  benign  tumors  in  mind  and,  running  over 
them,  you  see  at  once  that  this  must  be  a  fatty 
tumor  or  lipoma.  After  all,  it  makes  little 
difference  what  you  call  it.  The  method  of 
your  examination  concerns  us  at  present,  and 
if  you  have  learned  to  take  a  broad  view  of 
your  case,  to  approach  it  without  rush  or  flurry, 
and  to  observe  accurately  those  few  important 
details  of  which  I  have  spoken,  the  giving  a 
name  and  the  assigning  treatment  will  natu- 
rally and  readily  follow. 


LECTURE    II 


INCISED    WOUNDS 


Gentlemen  :  Twenty  years  ago  Mr.  Sampson 
Gamgee  published  in  London  one  of  the  very 
best  books  in  EngHsh  that  is  known  to  me,  on 
the  treatment  of  wounds  and  fractures. 

After  describing  in  some  detail  the  patho- 
logical conditions  which  are  met  with  in  these 
phenomena,  he  goes  on  to  lay  down  the  car- 
dinal principle  of  support  for  the  injured  part, 
and  this  he  recognizes  as  the  one  essential  in 
the  therapeutics  of  traumatic  surgery. 

I  shall  have  much  to  say  as  to  the  meaning 
of  that  word  "  support."  In  the  time  of  Mr. 
Gamgee 's  writing,  the  word  asepsis,  in  the 
modem  sense,  had  hardly  been  invented;  but 
it  has  now  come  not  altogether  justly  to  usurp 
the  honors  of  surgical  support ;  for  in  the  consid- 
eration of  all  wounds,  whether  of  the  soft  or 
hard  parts,  in  which  there  has  been  any  sort  of 
disturbance  of  continuity,  you  should  have 
constantly  in  mind  that  that  severed  continuity 
must  promptly  be  restored ;  that  those  restored 
parts  must  be  absolutely  immobilized  and  sup- 


13 


14  CLINICAL  TALKS 

ported,  and  that  this  work  must  be  done  under 
aseptic  conditions. 

I  show  you  here  a  simple  case  in  point.  This 
man  is  a  tinsmith,  thirty  years  old,  sound  and 
vigorous.  About  two  hours  ago,  while  at  his 
work,  he  cut  through  the  skin  and  fascia  of 
his  palm,  leaving  as  you  see,  a  clean,  straight 
wound,  extending  about  three  inches  across 
the  hand. 

Let  us  see  how  we  may  apply  our  two  prin- 
ciples, support  and  asepsis.  We  must  regard 
what  we  have  to  do  as  a  surgical  operatien. 
The  whole  field  of  the  wound  —  and  in  this  case 
the  field  is  the  man's  hand  —  is  sterilized,  so 
far  as  may  be  in  the  manner  with  which  you 
are  familiar,  —  a  thorough  scrubbing  with  soap 
and  water,  followed  by  immersion  in  chlorin- 
ated soda  and  wiping  with  cotton  sponges 
dipped  in  pure  alcohol.  The  hand  is  then 
immersed  for  two  minutes  in  an  alcoholic  so- 
lution of  bichloride  of  mercury,  i  to  3,000.  The 
hand  and  arm  are  then  wrapped  in  a  clean, 
steamed  towel,  and  the  patient  sits  before  me 
with  his  arm  outstretched,  palm  upward,  upon 
the  table.  Meanwhile  I  have  cleansed  my  own 
hands  with  soap,  water  and  alcohol,  and  have 
put  on  rubber  gloves,  which  have  been  steril- 
ized by  boiling.  I  have  gone  into  this  matter 
in  some  detail  with  you,  because  details  in 
asepsis  are  the  sine  qua  non  of  successful  sur- 


ON   MINOR   SURGERY  15 

gery,  and  I  do  not  expect  to  repeat  again  what 
I  have  just  told  you. 

Let  us  now  examine  the  wound.  We  must 
be  sure  always  that  no  foreign  substance  re- 
mains in  its  depths,  and  in  this  case  we  find 
none.  As  I  hold  the  wound  open,  you  see  the 
extensive  tear  in  the  palmar  fascia.  Perhaps 
I  am  overscrupulous  in  closing  this,  but  I 
believe  that  by  so  doing  I  shall  hasten  the 
restoration  of  function.  I  close  it,  as  you  see, 
with  three  interrupted  catgut  stitches,  using 
the  curved  needle  rather  than  the  straight  one. 
That  leaves  me  the  skin  wound  of  the  palm, 
which  lies  together  without  gaping.  The 
severed  edges  are  dusted  with  a  simple  drying 
powder,  aristol;  a  bit  of  crepe  lisse  laid  across 
and  secured  with  collodion  further  supports 
them.  T  then  apply  a  bit  of  absorbent  cotton 
also  held  down  with  collodion  about  the  edges, 
forming  what  we  call  the  "cocoon  dressing." 

Now  you  will  say  that  sufficient  has  been 
done  to  assure  a  prompt  and  sound  healing  by 
the  first  intention;  but  I  ask  you  to  observe 
that  the  second  only  of  our  cardinal  principles 
has  been  applied  up  to  this  point.  A  reason- 
ably accurate  asepsis  has  been  provided;  why 
is  not  that  sufficient,  and  why  do  I  go  on  to 
apply  the  first  principle  —  support  and  im- 
mobilization? A  very  simple  experiment  on 
your  own  fingers  will  illustrate  the  reason.     If 


i6  CLINICAL  TALKS 

you  prick  your  finger  sharply,  tie  an  elastic 
band  around  it  and  let  it  hang  down  for  a  few 
minutes,  you  will  find  that  the  whole  finger 
shortly  will  throb  painfully,  and  the  pricked 
wound  will  smart  and  ache.  Now  remove  the 
rubber  band,  place  the  hand  upon  the  opposite 
shoulder,  and  hold  it  there  steadily;  you  will 
quickly  experience  relief  and  a  sense  of  com- 
fort. The  series  of  phenomena  which  you  have 
experienced  are  not  dissimilar  from  what  will 
occur  in  this  man's  wounded  palm.  Were  I 
to  leave  his  hand  unprotected,  except  for  the 
cotton  and  collodion,  he  would  naturally  swing 
it  at  his  side.  Almost  at  once  the  process  of 
repair  will  have  begun  —  there  will  be  the  in- 
evitable increased  blood  supply  in  the  wounded 
parts,  a  certain  amount  of  exudation  will  go 
on,  the  venous  circulation  will  be  slightly  im- 
peded, and  all  these  conditions  will  be  accent- 
uated by  hypostasis,  if  his  hand  hangs  down; 
in  other  words,  the  reparative  process  will  be 
interfered   with . 

You  know  that  hitherto  we  have  been  able 
to  devise  no  means  of  disinfecting  thoroughly 
the  skin.  The  epidermis  may  be  scrubbed 
and  treated  with  chemicals  until  it  is  fairly 
free  from  micro-organisms,  but  the  corium 
cannot  be  touched  by  such  methods,  and  in  the 
corium  normally  there  are  to  be  found  patho- 
genic   organisms,    mostly     the     staphylococcus 


ON    MINOR  SURGERY  17 

epidermidis  albus.  You  must,  bear  in  mind,  too, 
that  in  the  aseptic  operations  of  surgery  we 
have  three  principal  sources  of  infection  to 
consider:  First,  the  instruments;  second,  the 
dressings  and  suture  materials;  and,  third,  the 
skin,  whether  of  patient  or  operator.  At  the 
present  time  we  have  advanced  so  far  that  we 
have  eliminated  the  first  two  sources.  Instru- 
ments properly  boiled  carry  no  organisms; 
dressings  and  suture  materials  properly  steamed 
and  prepared  are  sterile.  So  we  come  to  the 
third  source,  the  skin.  Even  that  to  a  large  ex- 
tent may  be  ruled  out,  for  we  now  wear  aseptic 
gloves, —  surgeons  and  all  assistants, —  so  that 
we  are  left  with  the  patient  himself  as  the  one 
most  important  carrier  of  possible  infection; 
and  after  the  most  scrupulous  care  in  prepara- 
tion, the  patient's  skin  must  carry  in  its  deep 
parts  pathogenic  organisms,  as  we  have  seen. 
One  asks.  Why  do  not  these  bacteria  always 
produce  sepsis?  Because  to  do  so  they  must 
be  present  in  great  numbers,  or  else  they  must 
fall  upon  suitable  soil,  or  both. 

I  need  not  review  with  you  here  the  well- 
known  fact  that  in  varying  degrees  patients 
carry  in  their  own  tissues  disease-resisting  ele- 
ments; suffice  it  only  to  remind  you  that  or- 
ganisms which  will  grow  and  multiply  in  and 
infect  one  man  will  fall  harmless  upon  another; 
and  here  is  your  practical  point,  that  in  a  great 


i8  CLINICAL  TALKS 

many  cases,  by.  appropriate  treatment  you 
may  help  to  bring  nearer  to  immunity,  you 
may  fortify  the  resisting  powers  of  your  indi- 
vidual patient.  There  again,  as  I  said  at  our 
last  exercise,  you  see  the  importance  of  study- 
ing your  patient's  general  condition. 

So  it  is  practically  in  the  patient's  own  skin, 
and  there  chiefly,  that  we  must  look  for  a  source 
of  sepsis. 

What  became  of  these  organisms  at  the  time 
this  man  received  this  cut?  Some  of  them 
were  undoubtedly  carried  into  the  deeper  parts, 
some  of  them  still  remain  on  the  cut  edges,  and 
others  will  be  forced  into  the  wound  itself  and 
into  the  general  circulation  during  the  early 
hours  of  repair.  Now  this  man's  hand  has 
been  relieved  of  a  large  number  of  organisms 
by  our  antiseptics.  We  must  strive  to  render 
the  deep  parts  of  the  field  infertile.  No  better 
medium  exists  for  the  growth  of  organisms 
than  a  stagnant  or  sluggish  blood  supply,  and 
that  condition  exists  to  perfection  when  we 
leave  the  man's  hand  hanging  at  his  side.  I 
now  place  it  high  upon  his  chest  and  secure  it 
in  a  sling. 

We  have  now  provided  for  asepsis  and  eleva- 
tion. Is  there  anything  further  that  may  help 
to  hasten  his  recovery?  There  is,  and  it  is  that 
surgical  immobilization  to  which  I  have  already 
called  your  attention. 


ON   MINOR   SURGERY  19 

If  I  leave  the  hand  unconfined  except  by  the 
Hght,  supporting  shng,  there  will  be  nothing  to 
prevent  his  withdrawing  it  from  the  sling,  and 
there  will  be  nothing  to  prevent  his  using  the 
hand  and  fingers  even  if  elevated. 

Here,  again,  you  may  ask.  What  harm  can 
possibly  result  from  such  use?  We  have  con- 
ceived of  an  exudation  essential  to  the  heal- 
ing process  in  the  palm;  we  have  conceived 
of  an  increased  flow  of  blood  to  the  part; 
we  can  further  see  how  the  support  of 
the  arm  has  improved  the  venous  circulation, 
and  it  takes  very  little  imagination  to  under- 
stand how  the  action  of  the  muscles  dragging, 
pulling  and  contracting  may  well  keep  up  an 
irritation  which,  superadded  to  the  other  con- 
ditions, will  stimulate  a  bacteriological  activity 
and  initiate  a  sepsis. 

These  are  involved  conceptions,  but  are  re- 
quired to  illustrate  a  condition  which,  after  all, 
is  simple  enough;  again  we  come  back  to  our 
point  and  say  that  the  one  thing  left  and 
needful  for  the  repair  of  this  man's  wound  is 
immobilization. 

Perfect  immobilization,  in  the  surgical  sense, 
is  far  from  being  the  simple  thing  you  might 
suppose.  It  is  not  readily  attained;  and  with- 
out giving  careful  thought  to  the  anatomy  of 
the  parts,  it  cannot  be  attained.  Take  the 
instance  of  this  man's   wounded   hand.     What 


20  CLINICAL  TALKS 

are  the  important  structures  which  go  to  make 
up  the  anatomy  of  the  palm  and  adjacent  parts? 
Obviously  they  are  the  skin  and  fascia,  the 
underlying  tendons  and  muscles,  and  the  bones. 
We  cannot  keep  the  wound  in  a  state  of  surgical 
rest  unless  we  immobilize  the  adjacent  struct- 
ures, and  that  means  that  we  must  tie  up  the 
muscles  of  the  part.  Those  muscles  are  the 
extensors  and  flexors  of  the  hand,  and  their 
origin  is  about  the  condyles  of  the  humerus 
and  in  the  forearm,  a  fact  elementary  and 
obvious  enough,  but  surprisingly  overlooked 
often.  So  we  must  carefully  bandage  and 
restrain  the  movements  of  the  forearm.  Ob- 
serve now  a  point  which  I  must  emphasize 
repeatedly.  Never  apply  for  immobilization 
a  bandage  close  to  the  skin  or  over  a  thin  inter- 
vening pad.  Learn  always  to  use  elastic 
compression.  You  see  that  I  now  cover  this 
patient's  hand  and  forearm  with  six  or  eight 
layers  of  sheet  wadding,  —  an  elastic,  very 
slightly  absorbent  material,  which  will  not  be- 
come caked  and  matted  with  perspiration.  Be- 
tween alternate  layers  of  the  wadding  I  place 
four  strips  of  moistened  mill  board  —  two  laid 
straight  down  the  arm  and  two  twisted  spirally 
about  it.  These  harden  as  they  dry  and  lend  an 
added  stiffness  and  elasticity  to  the  dressing. 
So  far  the  application  looks  very  cumbersome 
and   unwieldy,    but   with   this    cotton   roller   I 


ON   MINOR  SURGERY  21 

now  carefully  and   snugly  bind  the  whole  into 
place.     I  pull    the  bandage  very  tight,  greatly 
diminishing  the  bulk   of    the  dressing,   so  that 
when  completed  it  appears  to  be  of  moderate 
proportions.      If    you    handle    the     completed 
dressing  you  find  that  it  is  quite  elastic  to  the 
touch,  and  that  it  exerts  everywhere  a  perfectly 
equable    compression.     It    controls    absolutely 
the  muscles;    no  movement    can  go  on  under- 
neath it,  yet  it   is  extremely  comfortable.     It 
is  tight,  but  it  does  not  constrict.     By  its  firm 
contact    everywhere  with  the  underlying  parts 
it  moderates  and    controls   the  circulation,  but 
it  does  not  occlude   it.      Here  you  have  illus- 
trated on  a   large  scale    the  principles  of  com- 
pression which   you  apply  when  you  seize  and 
compress    gently    and    bring   comfort    to    your 
sore   thumb,  which  throbs  and  aches  with  the 
beginning  of  a  "run-round."     So  now  you  see 
employed  the    four  remedies  which   you   must 
learn  to  apply  in  the   dressing  of   all  wounds: 
asepsis,     elevation,    immobilization,    and    com- 
pression, and   the  last  three  imply  support,  — 
remedies    which    may   be    modified    in    degree 
often   to   suit    special    conditions,    perhaps  em- 
ployed with   over-scrupulous   care  in  this   par- 
ticular case,  but  always  important,  always  to  be 
borne  carefully  in  mind;  to  become  as  much  a 
part  of  your  instinct  and  training  as  that  anti- 
septic conscience  of  which  we  have  heard  tell. 


2  2  CLINICAL  TALKS 

Here  are  two  cases  which  illustrate  the  re- 
sults of  proper  and  improper  treatment.  This 
lad  received  a  ragged  four-inch  wound  of  the 
wrist  from  falling  on  a  broken  bottle  some  ten 
days  ago.  The  skin  cut  you  see,  but  I  must 
tell  you  —  a  fact  not  so  obvious  —  that  the  ^ 
superficialis  volse  artery  and  one  tendon  of 
the  flexor  sublimis  digitorum  were  severed. 
When  brought  in  here,  about  three  hours  after 
the  accident,  the  boy's  arm  was  found  tied  up 
tightly  with  a  knotted  handkerchief,  the  wound 
gaping  and  ugly  looking,  where  cobwebs  —  a 
favorite  domestic  remedy  —  had  been  smeared 
over  it,  blood  still  oozing  from  the  artery,  and 
the  whole  hand  livid,  swollen,  and  very  painful. 

The  patient  was  laid  on  the  operating  table, 
the  handkerchief  removed,  the  arm  elevated 
in  the  air  and  supported  by  an  assistant  for 
about  five  minutes,  when  the  bleeding  was 
found  to  have  ceased,  the  swelling  to  have  sub- 
sided, and  the  hand  to  be  normal  looking  and 
painless.  Then  the  whole  arm  and  hand  were 
cleaned  and  disinfected  —  washed,  scrubbed,  and 
soaked,  as  I  have  shown  you,  not  dabbed  at 
and  mopped  over  with  a  futile  corrosive  sponge. 

The  two  ends  of  the  cut  vessel  were  secured 
and  tied  with  catgut,  the  severed  tendon  was 
united  by  fine  silk  stitches,  the  skin  edges  care- 
fully and  accurately  approximated  with  four  sil- 
ver wire  points,  —  which  I  prefer  in  the  case  of 


ON    MINOR   SURGERY  23 

these  ragged  cuts  of  the  wrist,  —  and  the  hand 
and  arm  put  up  in  the  manner  I  demonstrated 
to  you  in  the  case  of  the  tinsmith.  In  this  case, 
of  course,  the  wrist  was  secured  in  a  position 
of  sHght  flexion  to  relieve  tension  on  the  severed 
tendon.  Since  the  day  of  the  first  dressing  the 
patient  has  felt  perfectly  comfortable;  his 
temperature  has  been  normal  and  his  bodily 
functions  have  been  undisturbed.  Twice  dur- 
ing this  time  an  additional  tight  bandage  has 
been  applied  over  the  dressing,  which  had  be- 
come somewhat  loosened. 

The  apparatus  has  now  been  removed,  and 
I  call  your  attention  to  the  appearance  of  the 
hand  and  arm.  The  entire  limb  is  pale  and 
shrunken.  That  is  as  it  should  be.  The  hand 
looks  thin  and  normal,  the  fingers  are  flexible 
so  far  as  I  allow  them  to  be  moved.  The 
wound  is  a  simple  red  line  —  not  puffy,  not 
tender,  not  painful.  The  old  cocoon  dressing 
shows  a  little  dry  blood-stained  exudate.  I 
remove  carefully  the  silver  stitches  which  have 
admirably  supported  the  irregular  skin  edges, 
and  the  wound  is  found  practically  healed. 
Of  course  there  is  more  to  the  case.  That  ten- 
don wound  will  be  slow  in  healing,  and  the  hand 
must  be  protected  and  supported  for  some 
weeks  on  that  account,  but  so  far  as  our  simple 
incised  wound  is  concerned  it  need  trouble  us 
no  more.     The  dressing  was  dry  and  it  was  in- 


24  CLINICAL   TALKS 

frequently  renewed.  Napoleon's  famous  sur- 
geon, Baron  Larrey,  was  the  great  exponent 
of  that  method  a  hundred  years  ago.  When 
you  can  find  the  time,  read  what  he  says  in  his 
deHghtful  "Memoirs"  on  the  subject  of  infrequent 
dressings. 

Here  is  a  man  whose  story  is  not  so  happy. 
He  is  a  postman.  Five  days  ago  he  received 
a  cut  on  the  back  of  the  left  forearm,  being 
struck  by  a  piece  of  falling  window  glass.  The 
cut  was  about  six  inches  long.  Only  the  skin, 
thick  fascia  and  some  fibers  of  the  muscles 
of  the  extensor  group  were  cut.  There  was 
little  bleeding.  The  wound  was  cleaned  and 
covered  in  with  the  greatest  care,  but  a  sup- 
porting bandage  and  sling  were  omitted,  at  the 
man's  request,  as  he  said  they  would  interfere 
with  him  and  that  he  would  be  careful  not  to 
use  his  arm. 

He  reports  here  for  the  first  time  this  morn- 
ing, after  five  days  of  active  running  about, 
swinging  the  arm  at  his  side.  You  see  the 
state  of  his  wound  and  compare  it  with  that  of 
the  lad  with  the  severed  tendon.  Here  is  a 
distinctly  reddened  area  extending  for  an  inch 
all  about  the  cut,  the  edges  of  which  are  in- 
fected and  slightly  swollen.  I  remove  one 
stitch  and  find  it  is  followed  by  a  drop  of  pus. 
The  man  says  that  the  wound  has  ached  for  the 
past  two  days,  and  that  he  has  felt  "feverish" 


ON   MINOR   SURGERY  25 

and  uncomfortable.  We  find  his  temperature 
to  be  99.4°  F.,  as  you  see.  The  arm  has  not  the 
shrunken,  cool,  almost  anemic  look  that  we  saw 
in  the  last  case,  but  is  distinctly  warm  and  full. 
Fortunately,  no  great  damage  has  been  done  as 
yet.  By  appropriate  treatment  the  initial  sep- 
sis may  be  checked,  but  the  man  iias  delayed 
his  convalescence  by  several  days,  and  we  have 
a  series  of  troublesome  dressings  to  occupy  us, 
which  I  shall  explain  on  a  subsequent  day. 

So  much  for  the  three  cases  of  simple  incised 
wounds.  They  have  been  striking  types  and 
have  told  their  own  story,  yet  I  must  qualify 
that  story  in  a  few  words,  else  you  would  leave 
this  room  with  a  false  idea  of  the  possibilities 
and  limitations  of  our  art. 

All  incised  wounds  carefully  cleaned  and  put 
up  with  compression  and  elevation  do  not  heal 
promptly,  nor  do  all  wounds,  lacking  that  sup- 
port, become  septic.  If  there  is  any  one 
thing  true  of  surgical  therapeutics  it  is  that 
there  is  in  it  no  place  for  dogma.  Beware  of 
the  surgeon  or  physician  who  says,  thus  and 
thus  shall  it  be  done  and  no  otherwise.  Such 
precepts  make  of  surgery  an  exact  science, 
which  it  is  not,  and  the  men  who  presume  to 
apply  to  it  ironclad  rules  have  to  change  their 
dogma  from  year  to  year. 

But  there  are  broad  general  principles  which 
you  will  find  safer  than  dogma.     Two  of  those 


26  CLINICAL   TALKS 

broad  principles  I  have  shown  you  to-day; 
asepsis,  rigid  asepsis,  must  be  your  sheet  anchor 
in  all  surgical  work.  Physiological  support, 
immobilization,  compression,  next  after  asepsis, 
are  essential  for  the  safe  and  prompt  healing 
of  the  great  majority  of  wounds. 


LECTURE    III 


SIMPLE    FRACTURES 


Gentlemen:  Percival  Pott  fell  down  in  a  Lon- 
don street  and  broke  his  leg  a  hundred  and 
thirty  years  ago.  He  got  well  and  wrote  about 
it,  and  since  then  surgeons  have  known  more 
about  fractures  than  they  knew  before.  Pott's 
famous  fracture  marks  an  era  in  our  annals. 
From  that  time  to  the  present  our  knowledge 
has  been  growing  more  definite,  until  to-day, 
with  x-ray  plates  for  aid  in  diagnosis  and  the 
admirable  book  on  treatment  by  our  friend 
Dr.  Scudder,  there  is  small  excuse  for  any  sur- 
geon's going  far  astray.  Yet  men,  even  the 
expert,  do  go  astray.  Probably  there  is  no 
class  of  cases  presented  to  us  which  is  so  easy  of 
misapprehension,  and  in  which  the  results  of 
misapplied  treatment  are  so  deplorable.  We 
have  no  time  here  for  a  general  lecture  on  frac- 
tures, but  I  will  speak  to  you  now  of  two  or  three 
simple  cases  and  illustrate  the  methods  of 
handling  them,  of  making  the  diagnosis,  and 
applying  a  suitable  treatment.      I   shall  speak 

27 


28  CLINICAL   TALKS 

only  of  closed  fractures,  or  as  they  are  more 
commonly  called,  simple  fractures. 

The  analogy  between  lesions  of  the  soft  parts 
and  of  bones  is  a  close  one.  The  processes  of 
repair  are  not  dissimilar  and  the  rules  of  treat- 
ment do  not  diverge  greatly.  But  our  analogy 
is  incomplete  in  one  important  particular.  In 
the  case  of  severed  soft  parts  union  will  take 
place  though  the  apposition  be  imperfect,  and 
though  the  united  structures  themselves  be 
dissimilar,  —  with  a  delayed  result,  to  be  sure, 
and  with  more  or  less  impairment  of  function; 
—  there  we  have  nature,  unaided,  working  out 
her  faulty  solution  of  the  problem.  But  in 
the  case  of  a  broken  bone,  our  art  must  be 
carefully  and  constantly  applied,  if  the  injured 
member  is  to  be  restored  to  any  sort  of  useful- 
ness. 

Here  is  a  boy,  sixteen  years  old,  who  while 
running  fell  against  a  curbstone  about  an  hour 
ago,  and  injured  his  forearm.  You  see  he  sup- 
ports the  damaged  limb  with  his  hand  and 
complains  bitterly  of  pain  half .  way  between 
the  elbow  and  the  wrist.  Let  us  proceed  with 
our  examination  carefully  and  painlessly  to  him, 
so  far  as  we  can. 

In  the  first  place  the  patient's  clothes  are 
stripped  off  to  the  waist,  thus  allowing  of  easy 
inspection  —  an  important  point.  In  remov- 
ing the  various  garments,  slip  off  the  coat  sleeve 


ON   MINOR   SURGERY  29 

from  the  sound  side  first;  then  the  injured  arm 
can  be  uncovered  without  undue  straining. 
Cut  the  shirt  down  the  front  and  shp  it  off  as 
you  would  a  coat. 

Allow  both  his  arms  to  hang  down,  and  ob- 
serve any  differences  in  them.  You  see  that 
the  affected  arm  hangs  limp  and  motionless; 
the  boy  cannot  raise  it.  It  appears  slightly 
swollen,  and  you  may  detect  a  slight  backward 
bowing.     So  much  for  inspection. 

Then  compare  the  two  arms  by  measure- 
ment. You  see  that  on  the  sound  side  the 
distance  from  the  tip  of  the  olecranon  to  the 
ulnar  styloid  is  ten  inches.  On  the  affected 
side  it  is  nine  and  one  quarter  inches.  Obvi- 
ously there  is  a  shortening  of  the  bones;  that 
means  fracture.  Is  it  a  fracture  of  one  or  both 
bones  ?  Of  both  certainly ;  for  if  the  ulna  alone 
were  broken,  the  radius  would  act  as  a  splint 
and  maintain  the  length  of  the  arm  with  little 
if  any  shortening.  So  you  have  very  properly 
concluded  that  you  have  to  deal  with  a  fracture 
of  both  bones  of  the  forearm,  and  so  far  you 
have  caused  not  the  slightest  pain.  It  remains 
to  locate  the  exact  seat  of  the  fracture.  Now  it 
may  be  necessary  to  hurt  the  patient  somewhat, 
but  if  you  proceed  cautiously,  he  will  bear  it 
well.  It  is  best  to  employ  an  assistant  —  two 
assistants  are  even  better.  The  patient  sits 
with    his    arm    extended    upon    a    table.      One 


30  CLINICAL  TALKS 

assistant  supports  the  elbow  firmly,  the  other 
holds  steadily  the  lower  part  of  the  forearm, 
making  gentle  traction;  for  there  is  spasm 
and  contraction  of  the  bruised  muscles.  I  now 
run  my  hand  gently  up  and  down  the  arm  and 
come  at  once  upon  this  area  of  thickening, 
about  five  inches  above  the  wrist.  That  area 
is  the  seat  of  fracture.  Grasping  the  arm  firmly 
above  and  below  the  injury,  while  the  assistant 
continues  to  make  traction,  I  mould  the  bones 
into  position,  reducing  the  over-riding  where 
the  distal  fragments  have  slipped  over  and  be- 
hind the  proximal.  While  so  moulding  I  ex- 
perience that  sensation  of  grating  or  crepitus 
of  which  you  hear  so  much.  While  we  keep  up 
the  traction  you  now  see  that  the  arm  has  been 
brought  back  to  the  same  measurement  as  its 
fellow.  If  the  spasm  had  been  very  strong  and 
reduction  of  the  fracture  impossible  without 
causing  great  pain,  we  should  have  given  the 
patient  an  anaesthetic. 

We  come  now  to  the  difficult  question  of 
support  and  immobilization,  for  as  John  Hunter 
said, ' '  The  first  and  great  requisite  for  the  res- 
toration of  injured  parts  is  rest."  Shall  we  em- 
ploy our  cotton  rollers  and  mill-board  strips 
with  elastic  compression?  That  certainly  would 
give  rest  to  the  parts,  and  it  has  at  times 
been  used  with  success  in  these  cases.  If  this 
were  the  fracture  of  but  one  bone  I  should  use 


ON    MINOR    SURGERY  31 

that  dressing.  As  a  rule,  however,  its  very- 
elasticity  renders  it  unsafe  when  we  need  exten- 
sion or  traction  to  keep  the  bones  from  again 
over-riding.  There  are  innumerable  splint  ma- 
terials, from  plain  strips  of  wood  to  moulded 
gutta  percha,  wood  fiber,  felting,  and  plaster 
of  Paris.  The  first  of  these,  known  among  us 
as  "splint  wood,"  and  the  plaster  of  Paris,  are 
convenient  and  are  in  common  use.  I  shall 
use  splint  wood  in  this  case,  as  the  arm  will 
probably  swell,  and  such  splints  can  be  removed 
easily  and  readjusted. 

There  remain  two  other  important  points 
for  you  to  consider  before  we  apply  the  dressing. 
You  can  lay  it  down  as  a  safe  general  rule  in  all 
fractures  of  the  long  bones,  unless  the  fracture 
occurs  close  to  the  end  of  the  bone,  that  the 
adjacent  joints  at  either  extremity  must  be 
immobilized,  otherwise  the  play  of  the  muscles 
would  not  be  held  in  check  and  with  the  move- 
ments of  the  joints  there  would  be  a  constant 
displacement  of  fragments.  Moreover,  with- 
out immobilizing  the  joints  the  required  exten- 
sion could  not  be  maintained.  In  this  case  we 
must  fix  the  elbow  and  the  wrist. 

The  second  point  is  that  with  fracture  of  both 
bones  of  the  forearm  and  the  possible  large 
resulting  calluses  which  sometimes  form,  the 
position  must  be  such  as  to  keep  the  shaft 
of  the  radius  as  far  as  possible  from  that  of  the 


32  CLINICAL    TALKS 

ulna,  else  all  four  wounded  bone  surfaces  might 
become  united  in  a  common  callus,  and  future 
rotation  be  impossible.  In  supination,  with 
the  palm  turned  upward,  the  shafts  are  well 
apart,  in  semi-pronation  they  are  somewhat 
farther  apart,  in  extreme  pronation  they  are 
thrown  close  together,  and  if  there  be  extensive 
laceration  of  soft  parts  it  is  possible  even  for 
the  distal  fragment  of  the  radius  to  become 
united  with  the  proximal  fragment  of  the  ulna. 

In  our  present  case  I  have  the  arm  held 
firmly  in  semi-pronation  and  proceed  to  apply 
my  splints  —  a  simple  matter  after  all  this 
explanation. 

The  splints,  of  light,  thin  wood,  should  be  a 
quarter  of  an  inch  wider  than  the  forearm. 
The  posterior  splint  extends  from  three  inches 
above  the  fracture  to  the  metacarpo-phalangeal 
joints;  the  anterior  splint  from  the  same  point 
on  the  forearm  to  the  middle  of  the  palm,  and 
a  large  crescentic  groove  is  cut  out  of  its  side  to 
avoid  pressure  on  the  thenar  eminence.  The 
splints  are  carefully  padded  with  six  sheets  of 
wadding,  with  extra  small  pads  on  the  anterior 
splint  to  conform  to  the  contour  of  the  wrist. 
Then  an  *  *  internal  angular  ' '  splint  of  moulded 
tin  is  similarly  prepared  to  support  the  elbow. 

While  the  arm  is  held  steadily  by  an  assist- 
ant, who  stands  on  the  patient's  outer  side,  I 
apply  these  splints  and  fasten  them  firmly  but 


ON    MINOR   SURGERY  S3 

not  tightly  in  place  by  four-inch  adhesive  straps, 
passed  round  one  and  a  half  times.  There  are 
three  straps  —  one  about  the  proximal  end  of  the 
splints,  one  about  the  wrist,  and  one  about  the 
palm,  embracing  the  posterior  splint  only. 
This  last  strap  is  very  important,  as  by  its  firm 
pull  on  the  posterior  splint  it  keeps  up  traction. 
Then  the  elbow  splint  is  applied  with  three 
straps  —  one  at  each  end  and  one  just  below  the 
bend  of  the  elbow.  The  whole  I  cover  with  a 
cotton  roller,  snugly  put  on.  That  is  a  fairly 
comfortable  dressing,  but  you  must  still  be  on 
the  lookout  for  trouble.  Keep  the  patient  in 
sight  for  half  an  hour,  and  see  that  there  is  no 
return  of  pain  before  he  leaves  the  hospital. 
Increase  of  pain,  throbbing  pain,  especially  if 
the  fingers  become  swollen  or  blue,  means  that 
your  splints  are  too  tight.  You  must  remove 
and  reapply  them.  Then  you  must  support 
the  arm  in  a  comfortable  sling  before  sending 
the  patient  out.  If  he  goes  from  the  hospital 
in  pain,  you  may  be  certain  that  he  will  suffer 
greatly  before  to-morrow,  and  the  frequent  swel- 
ling of  the  arm,  against  the  immovable  splints, 
will  give  rise  to  ugly  skin  sloughs. 

So  much  for  this  familiar  dressing  which  you 
see  applied  almost  daily  in  our  clinics.  But 
the  after-treatment  —  that  is  not  always  so 
easy;  it  calls  often  for  the  best  judgment  and, 
when  neglected,  may  lead  to  serious  deformity. 


34  CLINICAL  TALKS 

Moreover,  these  forearm  fractures  not  uncom- 
monly result  in  non-union,  and  against  that 
you  must  guard- 
One  advantage  of  this  use  of  open  splints  is 
that  they  are  easily  removed  for  inspection  of 
the  wound.  I  will  ask  this  boy  to  return  here 
daily  for  three  days.  If  I  find  the  arm  pain- 
less, and  the  swelling  not  conspicuous,  I  shall 
then  have  him  wait  until  a  week  from  the 
accident  has  elapsed  before  I  change  the  splints. 
Here  is  another  patient  with  a  similar  frac- 
ture ten  days  old,  whom  I  have  kept  to  sh(5w 
you.  You  see  that  on  removing  the  bandage 
the  position  of  the  bones  appears  good,  the 
swelling  has  subsided,  and  the  plaster  straps 
are  a  little  loose.  The  splints  are  now  off,  and 
a  slight  callus  is  felt  over  the  seat  of  fracture. 
The  skin  is  shrunken  and  pale  and  the  elbow  and 
wrist  are  moved  with  some  pain  and  difficulty. 
Here  is  your  opportunity,  if  you  want  to  help 
the  union  and  hasten  convalescence,  to  do  a 
piece  of  work  usually  neglected,  but  for  which 
your  patient  will  bless  you.  Call  in  a  compe- 
tent masseur,  if  you  can  find  one,  and  have  him 
manipulate  the  elbow,  the  wrist  and  the  tissues 
about  the  fracture  for  half  an  hour  every  day. 
The  arm  must  be  securely  held  on  a  firm  cushion 
or  on  the  padded  table  while  the  masseur  is  at 
work.  He  kneads  the  muscles  about  the 
joints,  he  loosens  slight  adhesions,    he    restores 


ON  MINOR  SURGERY  35 

the  stagnant  lymphatic  circulation,  he  stimu- 
lates the  circulation  of  the  whole  arm,  and  by 
thus  improving  the  nutrition  of  the  parts  he 
hastens  the  union  of  the  broken  bones.  If  time, 
permitted  I  could  tell  you  more  about  this, 
valuable  measure  of  massage  in  fractures.  I 
have  employed  it  for  years  in  such  cases  as 
have  come  under  my  care,  and  am  constantly 
impressed  with  its  advantages  —  in  the  hasten- 
ing of  repair,  in  the  early  restoration  of  func- 
tion, perhaps  best  of  all  in  the  sense  of  well- 
being  given  at  the  time,  and  in  the  feeling  of 
security  and  confidence  so  soon  as  the  patient 
reaches  the  stage  at  which  active  movements 
begin  to  succeed  these  passive  ones.  Under 
the  old-fashioned  treatment  the  arm  was  like  a 
prisoner  confined  for  weeks  in  a  dark,  narrow 
cell,  to  emerge  at  the  last,  pale,  timid,  spiritless, 
broken-down,  — who  must  wait  weeks  yet  before 
his  proper  vigor  returns  to  him.  With  massage 
you  let  in  air  and  light  upon  your  captive;  his 
windows  are  thrown  open  daily  and  he  is  taken 
for  a  brisk  walk,  as  it  were,  about  the  prison 
yard.  At  the  end  of  his  confinement  he  returns 
to  the  former  life  with  his  force  but  little 
abated  and  his  zest  sharpened  for  the  work 
of  the  world. 


LECTURE    IV 


LACERATED    WOUNDS 


Gentlemen:  The  first  patient  I  have  to  show 
you  this  morning  presents  a  condition  calHng 
for  the  nicest  judgment.  * 

He  is  a  teamster,  forty  years  old,  sound  and 
vigorous.  Last  evening  while  unloading  his 
wagon  he  let  fall  a  heavy  iron  bar,  the  end  of 
which  struck  his  calf  and  inflicted  this  ragged 
triangular  wound.  Some  six  inches  of  skin 
are  torn  up,  the  muscles  are  lacerated  and  the 
head  of  the  fibula  is  exposed.  The  bleeding 
has  been  inconsiderable.  At  the  time,  he  wrapped 
an  old  handkerchief  about  the  leg,  passed  a 
painful  night,  and  now  comes  here  for  treat- 
ment. 

Forty  years  ago,  in  the  days  of  the  Civil  War, 
such  an  injury  might  eventually  have  led  to 
amputation;  even  now  it  is  not  without  its 
dangers.  Septic  material  has  undoubtedly  been 
carried  deeply  into  the  leg.  The  iron  bar 
itself  was  unclean,  and  the  man's  well-worn, 
sweat-soaked    working   trousers    are    far    from 

36 


ON   MINOR   SURGERY  37 

aseptic,  while  the  skin  of  the  leg  itself  is  loaded 
with  organisms. 

Two  courses  are  open  to  us  —  to  clean  up  the 
leg  and  the  wound,  apply  wet  antiseptic  dress- 
ings, and  look  for  a  slow  healing  by  granulation, 
or  to  bring  the  severed  skin  and  soft  parts  back 
into  place  and  try  to  obtain  a  prompt  healing 
by  primary  union. 

I  shall  adopt  the  latter  course,  and  I  believe 
that  by  the  application  of  our  two  great  surgi- 
cal principles  —  asepsis  and  physiological  rest 
—  we  may  look  for  a  good  result.  That  pleas- 
ant old  Frenchman,  Le  Dran,  in  1735,  used  to 
tell  his  classes  that  in  such  cases  as  this  he 
always  tried  for  a  primary  union,  because  if 
that  failed  through  catching  cold  in  the  wound 
he  could  take  out  his  stitches  and  look  for  a 
second  intention.  I  suppose  that  phrase  ' '  catch- 
ing cold  "  is  as  old  as  Hippocrates. 

Of  course  Le  Dran's  reasoning  still  holds 
good,  though  to  us  now  such  a  method  seems 
a  half-hearted  way  to  approach  a  surgical 
problem. 

We  begin  our  proceedings  by  etherizing  the 
patient.  It  is  cruel  as  well  as  stupid  to  at- 
tempt so  painful  and  extensive  a  dressing  as 
this  without  an  anaesthetic.  The  leg  is  shaved 
and  thoroughly  scrubbed,  then  the  wound  is 
mopped  out  with  peroxide  of  hydrogen,  fol- 
lowed by  bichloride  alcohol  i   to  3,000.      Bits 


38  CLINICAL   TALKS 

of  torn  clothing  and  dirt  are  picked  out  first,  of 
course,  and  we  are  now  ready  to  proceed.  If 
you  look  carefully  you  see  that  these  fragments  of 
torn  muscle  are  viable ;  they  bleed  easily  and  can 
be  reunited.  The  sewing  of  them  properly  is 
very  important  for  two  reasons  —  because  if 
left  loosely  flapping  no  good  muscle  union  will 
result  and  the  leg  will  be  just  so  much  weak- 
ened, and  because  the  drawing  of  them  together 
fills  up  the  cavity  between  and  prevents  the 
collection  of  blood  where  it  would  serve  as  a 
culture  medium  in  that  "dead  space."  Here 
again  I  cannot  forbear  quoting  wise  old  Le 
Dran,  who  said  that  in  a  deep  wound  in  which  the 
muscles  were  divided  obliquely,  the  deep  stitches 
should  be  passed  so  as  to  run  parallel  with  the 
muscle  fibers  and  not  obliquely,  as  would  be 
natural  in  sewing    up  an  incised  wound. 

Then  having  closed  in  the  deep  parts,  I  lead 
into  the  bottom  of  the  wound  a  single  strip  of 
absorbent  tape  or  wick,  placing  it  gently  and 
loosely,  that  it  may  act  as  a  drain  and  not  as  a 
cork.  The  skin  is  now  drawn  over  the  restored 
muscle  and  stitched  into  place  with  a  half  dozen 
silver  or  silkworm-gut  stitches.  The  leg  is  again 
washed  with  bichloride  alcohol  and  elevated  in  the 
air,  thoroughly  to  drain  the  veins  and  promote 
freer  circulation.  Our  asepsis  is  complete;  now 
comes  the  second  step  —  support  and  immo- 
bilization. 


ON   MINOR   SURGERY  39 

In  this  case  we  must  bind  the  muscles  from 
the  toes  to  the  middle  of  the  thigh.  First,  I 
cover  the  wound  with  a  handful  of  loose  absor- 
bent gauze,  to  act  as  a  drain  and  reservoir  for 
the  inevitable  discharges,  then  firmly  and 
snugly  I  apply  our  mill-board  and  wadding 
rollers.  You  see  how  securely  they  hold  the 
leg  and  how  the  knee  and  ankle  both  are  im- 
mobilized without  discomfort. 

We  cannot  put  the  leg  in  an  ordinary  sling 
as  we  did  the  arm,  but  we  can  keep  it  elevated, 
and  so  add  greatly  to  the  patient's  comfort. 
Of  course  this  man  must  lie  in  bed  for  a  few 
days.  We  swing  a  gauze  hammock  from  a  rod 
which  is  stretched  from  the  headboard  to  the 
foot  of  his  bed.  In  this  hammock  the  whole 
leg  rests,  from  foot  to  hip.  That  is  a  most 
satisfactory,  comforting  device.  It  gives  us 
our  required  support  and  elevation,  and  as  it 
swings,  it  allows  the  patient  to  shift  himself 
about  and  even  turn  in  bed  without  disturbing 
the  wounded  leg;  for  as  the  body  moves  the 
hammock  swings,  but  the  leg  remains  relatively 
at  rest. 

To-morrow  the  wick  will  be  removed  under 
the  strictest  aseptic  precautions;  the  leg  will 
be  bound  up  again,  and  at  the  end  of  a  week  I 
hope  to  be  able  to  show  it  soundly  healed. 

Ambroise  Pare  wrote  to  his  petit  maistre  in 
1580:   "M.  le  Prince  de  la  Roche-sur-Yon,  who 


40  CLINICAL   TALKS 

dearly  loved  the  king  of  Navarre,  drew  me  aside 
and  asked  if  the  wound  were  mortal.  I  told 
him  Yes,  because  all  wounds  of  great  joints, 
and  especially  contused  wounds,  were  raortal;" 
and  in  the  sequel  the  King  of  Navarre  died. 

Five  years  ago,  a  friend  of  mine,  while  lead- 
ing a  landing  party  on  the  coast  of  Cuba,  was 
shot  through  the  elbow  by  a  Mauser  rifle.  The 
wound  was  properly  dressed  and  supported, 
and  in  the  course  of  a  month  the  use  of  the  arm 
was  restored  perfectly. 

Here  is  an  Italian  who  got  mixed  up  in  •a 
scuffle  last  night.  He  came  out  of  it  with  this 
ugly,  ragged  cut,  which  has  nearly  severed  the 
insertion  of  the  triceps  tendon  and  has  laid 
open  freely  the  elbow  joint  from  behind.  As 
I  hold  the  edges  of  the  wound  apart  you  see  the 
articulating  surface  of  the  olecranon  and  a  bit 
of  the  internal  condyle.  Let  us  attempt  to 
save  the  arm  with  a  useful  joint. 

The  man  is  etherized,  the  arm  carefully  dis- 
infected, and  while  an  assistant  holds  the 
wound  open  I  wipe  out  the  joint  with  the  little 
gauze  sponges  dipped  in  bichloride  alcohol  and 
then  douche  it  thoroughly  with  sterilized  water, 
taking  pains  all  the  time  not  to  bruise  or  other- 
wise injure  the  serosa,  lest  I  set  up  an  adhesive 
inflammation  which  might  lead  to  anchylosis. 

Next,  with  fine  chromicized  catgut  stitches, 
I  sew  up  the  rent  in  the  capsule  and  unite  accu- 


ON    MINOR    SURGERY  41 

rately  the  severed  ends  of  the  triceps  muscle. 
In  sewing  up  the  capsule  I  have  taken  special 
pains  to  evert  the  edges,  that  no  rough  surface 
be  turned  into  the  joint  to  cause  mechanical 
irritation.  Then  the  skin  wound  is  brought 
together,  and  covered  in  with  gauze  pads.  In 
the  final  binding  of  this  arm  we  have  to  meet  a 
problem  which  differs  from  most  of  those  en- 
countered in  the  upper  extremity.  We  can- 
not flex  the  elbow  and  support  it  in  a  sling,  for 
by  so  doing  we  should  run  the  risk  of  tearing 
the  freshly-sewn  triceps.  So  the  arm  is  put 
up  in  extreme  extension,  with  our  mill-board 
strips  to  preserve  fixation  and  plenty  of  cotton 
rollers  to  give  elasticity  and  comfortable,  even 
compression. 

This  man  must  not  be  allowed  to  go  out  with 
his  arm  swinging  at  his  side.  The  wound  is 
a  serious  one  and  demands  great  care  for  a  few 
days.  He  will  be  put  to  bed  and  the  arm  kept 
at  an  angle  of  45°,  either  on  pillows  or,  as  I 
prefer,  in  our  gauze  hammock. 

A  week  ago  to-day  I  was  asked  by  a  physi- 
cian in  a  neighboring  town  to  see  a  patient, 
with  a  view  to  an  amputation.  The  man  was 
suffering  from  a  wound  somewhat  similar  to 
this  last  one,  but  in  the  knee  joint. 

He  had  received  his  injury  ten  days  previ- 
ously. Not  realizing  its  gravity,  he  had  neg- 
lected to  call    a   physician,   contenting   himself 


42  CLINICAL  TALKS 

with  lying  in  bed  and  keeping  the  knee  wet  with 
appHcations  of  "  listerine."  My  friend  had  seen 
him  only  a  few  hours  before  my  visit.  I  found 
the  patient  to  be  a  middle-aged,  sturdy  sea- 
captain.  He  was  lying  in  bed  and  was  evi- 
dently in  pain.  There  was  a  punctured  wound 
on  the  outer  side  of  his  right  knee  joint.  The 
edges  were  gray  and  sloughy  looking,  and  a 
thin  pus  could  be  pressed  out  through  the 
opening.  A  culture  from  this  discharge  showed 
later  a  staphylococcus  infection.  The  whole 
knee  was  red,  boggy,  tender,  and  swollen,  the 
dimples  on  either  side  of  the  patella  being  oblit- 
erated, and  the  synovial  pouch  distended  three 
fingers'  breadths  above  the  patella.  The  man's 
temperature  that  morning  was  ioo°  F.,  and  his 
pulse  no;  his  face  was  flushed,  appetite  nil, 
and  the  picture  that  of  a  very  sick  man.  There 
was  present  a  leucocytosis  of  26,000. 

I  agreed  with  my  consultant  that  an  ampu- 
tation must  be  considered,  but  advised  making 
an  attempt  first  to  save  the  leg.  The  patient 
was  etherized,  the  leg  cleaned  up  and  the 
wound  enlarged  so  as  to  admit  of  thorough 
exploration  of  the  joint.  The  serosa  was  seen 
to  be  deeply  injected,  and  several  ounces  of  pus 
were  evacuated,  but  the  integrity  of  the  joint 
apparently  was  not  yet  affected.  The  whole 
interior  surface  was  carefully  and  laboriously 
mopped  with  peroxide  of  hydrogen  and  douched 


ON    MINOR    SURGERY  43 

with  sterilized  water.  A  counter-opening  on 
the  inner  side  of  the  patella  was  made  for  drain- 
age and  a  tape  was  inserted  in  either  wound. 
Then  a  large  absorbent  pad  was  placed  about 
the  knee,  the  leg  thoroughly  wrapped  and  sup- 
ported after  our  familiar  fashion  —  the  dress- 
ing extending  from  the  toes  to  the  groin.  The 
leg  was  slung  in  a  hammock,  a  quarter  grain 
of  morphia  hypodermically  was  administered, 
and  the  patient  was  left  with  careful  directions 
that  his  bowels  be  kept  open  by  salines  and  his 
strength  supported  by  frequent  liquid  nourish- 
ment and  a  drink  of  Scotch  whiskey  three  times 
a  day. 

Of  course  in  this  case  we  did  not  look  for  the 
restoration  of  a  sound,  flexible  knee  joint.  The 
best  outcome  to  be  expected  was  the  saving  of 
the  leg  with  a  stiff  knee.  I  did  not  hear  of  that 
man  again  until  last  night,  when  my  friend 
again  asked  me  to  see  him,  and  to  do  the  dress- 
ing. The  picture  he  presented  was  most  refresh- 
ing. Except  for  pallor  and  feebleness,  all  evi- 
dence of  sickness  had  left  him,  and  he  received 
me  with  the  comfortable  assurance  that  he  was 
well.  During  the  week  the  wicks  had  been 
changed  three  times  by  his  attendant,  and  I 
now  removed  them  for  good  and  all.  On  tak- 
ing off  the  dressing  I  found  the  leg  pale  and 
the  skin  shriveled  in  appearance,  with  the  fa- 
miliar  contour   of   the   joint    restored.      There 


44  CLINICAL   TALKS 

was  slight  though  rather  painful  motion,  which 
I  did  not  encourage.  The  two  wounds  were 
granulating  well.  I  replaced  the  apparatus, 
and  do  not  expect  to  see  the  patient  again. 

This  was  a  gratifying  result.  I  attribute  it 
to  the  man's  remarkably  good  general  condi- 
tion, supplemented  by  the  strict  enforcement 
of  our  cardinal  rules,  —  asepsis  and  support. 

Let  us  look  for  one  moment  at  this  other 
man  —  the  tinsmith,  whose  cut  hand  we 
sewed  up   ten   days   ago. 

It  has  not  been  seen  in  the  interval,  though 
he  has  reported  to  assure  us  of  his  comfort  and 
the  absence  of  pain.  Freed  of  its  dressings, 
you  see  that  the  wound  has  healed  per  primam, 
as  was  to  be  expected.  We  shall  confine  the 
hand  in  a  light  bandage  for  five  or  six  days 
longer  and  then  send  the  man  back  to  his  work. 

I  am  showing  you  good  results  only,  but  you 
must  not  conclude  from  them  that  surgeons 
are  wizards.  Bad  results,  unavoidably  bad 
results,  come  often  enough,  and  you  will  see  a 
plenty.  For  the  present,  we  are  illustrating  the 
constant  saying  of  Ambroise  Pare,  "I  dressed 
him,  and  God  healed  him." 


LECTURE    V 


COMPOUND     FRACTURES 


Gentlemen:  In  connection  with  the  subject  of 
lacerated  wounds  I  must  say  something  to-day 
about  compound  fractures.  They  are  no  more 
than  special  varieties  of  lacerated  wounds. 

These  fractures  were  regarded  with  extreme 
alarm  in  the  old  days,  and  are  still  not  to 
be  treated  cavalierly.  Chelius  of  Heidelberg 
wrote  in  1821  that  "the  inflammation  is  always 
very  great  and  requires  strict  antiphlogistic 
treatment,  blood-letting,  leeches,  cold  apphca- 
tions,  and  opium,"  and  that  mortification  and 
delirium  tremens  may  occur,  especially  in  old 
people.  "  If  sleep  do  not  take  place  death  is 
the  consequence.  On  dissection  frequently 
there  is  exudation  on  the  arachnoid,  pus  in  the 
joints  and  in  the  sheaths  of  the  tendons." 
All  of  which,  of  course,  results  from  the  fact 
that  we  have  to  deal  with  a  lacerated  and  easily 
infected  wound,  which  involves  a  structure  of 
low  vitality. 

Our  effort  therefore  must  always  be  to  sub- 
stitute a  closed  fracture  for  an  open  one,  and 


45 


46  CLINICAL  TALKS 

then  to  treat  the  damaged  bone  on  the  ordinary 
principles.  Here  again  we  come  back  to  that 
matter  of  rigid  asepsis  and  immobiHzation,  the 
latter  being  of  very  great  importance,  for  broken 
bones  which  are  not  held  strictly  at  rest  keep 
up  an  irritation  of  the  wounded  soft  parts, 
delay  healing,  favor  the  continued  outpouring 
of  a  sero-hemorrhagic  exudate,  and  so  provide 
a  medium  for  the  development  of  micro-organ- 
isms. 

The  young  woman  whom  I  show  you  was 
jostled  against  a  moving  cart  six  days  ago,  and 
her  arm,  thrust  between  the  spokes  of  the 
wheel,  was  severely  mangled.  On  being  brought 
in  here  shortly  afterwards,  it  was  found  that 
both  bones  of  the  forearm  were  broken  in  the 
middle  third  and  that  the  two  upper  fragments 
were  protruding  through  a  hole  in  the  skin  on 
the  dorsum.  The  house  surgeon  who  dressed 
the  case,  very  properly  was  not  content  with 
mere  reduction  of  the  fracture,  but  with  pains 
and  elaboration  restored  the  continuity  of  all 
the  severed  parts.  The  wound  was  enlarged 
by  free  incisions,  all  bleeding  completely 
checked,  the  bone  fragments  placed  in  apposi- 
tion, the  wound  thoroughly  douched  with  anti- 
septics, torn  muscles  and  fascia  sutured,  the 
skin  wound  closed  and  the  arm  carefully  dressed 
and  secured  in  the  wooden  splints  I  have  shown 
you. 


ON    MINOR   SURGERV  47 

This  free  opening  and  cleaning  up  of  com-  • 
pound  fractures  is  especially  important  when 
the  forearm  is  involved,  for  in  it  non-union  fre- 
quently occurs,  owing  to  the  interposition  of 
muscle  fragments,  or  tendons,  between  the  ends 
of  the  bones. 

In  the  present  case  the  arm  was  bound  firmly 
to  the  side  to  insure  perfect  rest.  After  recover- 
ing from  ether  the  young  woman  experienced 
little  pain;  the  next  morning  her  temperature 
was  99°  F.  It  never  rose  higher  and  we  may 
presume  fairly  that  the  superficial  wound  has 
now  healed  satisfactorily.  You  see  that  on  re- 
moving the  dressings  our  presumption  is  justi- 
fied. The  skin  wound  is  soundly  healed;  there 
is  no  swelling  or  redness,  and  we  are  left  to 
treat  the  case  as  a  simple  fracture. 

The  next  case  was  a  much  more  difficult 
one,  and  illustrates  a  point  which  I  made  for 
you  at  our  first  exercise.  This  man  is  a  brake- 
man,  forty  years  old.  Four  months  ago  he 
had  his  left  humerus  broken  by  being  crushed 
between  two  freight  cars.  The  fracture  was 
a  compound  one,  but  the  external  opening 
healed  readily,  and  under  a  properly  applied 
plaster  of  Paris  dressing  union  of  the  bone  was 
going  on  well,  as  we  supposed.  After  a  month, 
however,  non-union  was  apparent,  and  after 
two  months  the  condition  had  not  improved. 
A  careful  investigation  of   the  man's  past  his- 


48  CLINICAL  TALKS 

tory  then  revealed  the  fact  that  some  five  years 
ago  he  had  a  venereal  sore,  followed  by  an  in- 
guinal adenitis  and  a  skin  eruption,  for  which 
he  submitted  to  about  six  months  only  of  treat- 
ment. He  was  immediately  put  on  to  mercu- 
rials and  iodides  for  a  presumable  syphilis,  with 
the  result  that,  after  another  month,  fair  union 
had  been  established  and  now  we  find  his  left 
arm  as  sound  as  its  fellow.  That  question  of 
an  old  syphilitic  infection  is  never  to  be  lost 
sight  of  in  these  cases  of  delayed  union.  The 
other  more  frequent  general  diseases  which 
may  complicate  recovery  are  tuberculosis,  dia- 
betes, malaria  and  that  indefinite  thing  which 
we  call  rheumatism,  for  want  of  a  better  name 
and  understanding  of  its  true  nature. 

Our  third  case  was  a  more  serious  affair  than 
either  of  the  two  preceding,  but  is  interesting 
because  it  shows  how  bad  may  be  the  results 
which  sometimes  follow  the  careful  conserva- 
tive surgery  of  to-day. 

The  subject  is  a  man  of  sixty  who  has  all  the 
appearance  of  having  led  a  laborious  life.  He 
has  an  obvious  arterio-sclerosis,  though  a  thor- 
ough examination  of  the  chest  and  kidneys 
elicits  nothing  abnormal.  As  old  John  Aber- 
nethy  remarked  on  opening  his  surgical  lec- 
tures a  hundred  years  ago:  "Now  I  say  that 
local  disease,  injury,  or  irritation  may  affect  the 
whole    system,  conversely  that    disturbance   of 


ON   MINOR   SURGERY  49 

the  whole  system  may  affect  any  part."     That 
ancient  fact  is  the  crux  on  which  this  case  turns. 

The  man  is  a  weaver.  About  six  weeks  ago 
his  left  hand  was  caught  in  his  machine  and 
severely  torn  at  the  wrist.  The  radius  was 
fractured,  the  ulna  dislocated,  the  wrist  joint 
opened,  the  skin  and  other  soft  parts  over  the 
dorsum  severely  mangled,  and  he  was  brought 
in  here  with  the  hand  hanging  off,  attached 
only  by  the  skin  and  tendons  of  the  front  of  the 
wrist.  There  again  was  the  question  of  com- 
pleting the  amputation  which  the  machine  had 
begun,  or  of  attempting  to  save  the  hand.  I 
determined  on  the  latter  seemingly  hopeless 
undertaking. 

After  the  usual  careful  preparation,  two 
loose  fragments  of  the  radius  were  removed, 
including  the  articulating  surface,  and  the  pro- 
truding end  of  the  ulna  was  cut  off,  in  order  to 
convert  the  injury  from  a  compound  fracture 
and  dislocation  into  a  compound  fracture, 
which  would  be  more  likely  to  heal  than  would 
the  contused  and  lacerated  joint.  As  a  result 
of  this  removal  of  the  ends  of  the  forearm  bones, 
we  produced  a  partial  resection  of  the  joint, 
which  would  mean  for  us  at  best  a  hand  with 
considerable  impairment  of  motion.  Then  the 
torn  tendons  were  secured,  trimmed  up  and 
united,  tape  drainage  was  inserted,  the  skin 
wound  sewn  with  silver  wire,  and  the  arm  put 


so  CLINICAL   TALKS 

up  in  the  mill-board  apparatus.  The  patient  was 
put  to  bed  and  the  limb  slung  in  a  hammock. 

The  case  went  as  badly  as  it  could  well  have 
done.  That  night  the  patient's  temperature 
was  1 00°  F.,  and  his  pulse  100.  The  next  morn- 
ing the  temperature  and  pulse  were  loi  and  90 
respectively.  The  dressing  was  taken  down, 
the  skin  stitches  removed,  and  the  wound 
cleaned  up,  but  that  night  the  temperature  had 
reached  103°  and  the  pulse  120.  The  next 
day,  two  days  from  the  accident,  the  patient's 
condition  was  alarming.  With  temperature 
at  102°  and  pulse  112,  he  had  every  appearance 
of  being  thoroughly  septic,  as  it  is  called.  Evi- 
dently the  wound  was  an  active  streptococcus 
factory,  pouring  pyogenic  organisms  and  their 
products  into  the  general  circulation.  This 
we  must  conclude,  although  as  is  so  often  the 
fact  in  similar  cases,  cultures  of  the  man's  blood 
were  negative.  The  patient's  arm  showed  a 
striking  picture  —  such  a  picture,  fortunately, 
as  you  seldom  see  in  these  days.  The  wound 
was  sloughy  looking,  and  exuded  a  thin  saneous 
pus.  The  whole  forearm  and  hand  were  swol- 
len, tense,  red,  and  shiny.  The  skin  of  the  back 
of  the  hand  was  blue  and  necrotic  looking,  and 
it  was  evident  that  we  had  to  deal  with  the 
inception  of  an  acute  gangrene 

Not  least  significant  was  the  patient's  general 
appearance.     He  was  hectic,  anxious,  and  rest- 


ON   MINOR   SURGERY  51 

less,  with  that  almost  indefinable  septic  look, 
with  saffron  skin  and  injected  conjunctivae, 
which  experience  teaches  us  to  associate  with 
these  alarming  cases. 

Of  course  there  was  but  one  thing  to  do. 
The  rotting  arm  was  killing  the  man,  and  it 
must  be  taken  off.  I  amputated  it  about  three 
inches  above  the  limits  of  the  old  wound,  left  the 
flaps  wide  open  for  the  sake  of  more  complete 
drainage,  and  had  the  satisfaction,. the  next  day, 
of  finding  him  established  on  the  road  to  con- 
valescence.    The  further  story  is  uneventful. 

You  will  scarcely  find  a  case  to  illustrate 
better  the  extreme  danger  of  some  of  these 
compound  fractures,  and  the  bearing  which 
the  patient's  state  of  general  health  may  have 
on  the  local  lesion.  Here  the  man's  premature 
old  age,  and  the  general  impoverishment  of  his 
system,  consequent  upon  an  inefficient  circu- 
lation, were  the  underlying  and  salient  features. 
He  could  put  up  no  fight  against  the  overwhelm- 
ing bacterial  invasion,  and  so  capitulated  only 
in  time  to  save  his  life. 

In  a  city  the  place  to  see  compound  frac- 
tures is  at  the  general  hospitals.  You  will 
rarely  see  these  cases  in  private  practice.  Such 
injuries  occur  mostly  among  handicraftsmen, 
day  laborers,  and  those  persons  engaged  in  extra- 
hazardous vocations,  such  as  railway  trainmen, 
linemen,  roofers,  firemen,  and  the  like;  and  these 


52  CLINICAL   TALKS 

men  when  injured  are  commonly  taken  at  once 
to  a  hospital.  So,  too,  with  any  person  in  any 
walk  of  life  who  may  be  injured  in  a  street 
accident  —  he  is  immediately  hurried  here  by 
the  zealous  bystanders  or  police.  It  is  fortunate 
that  this  is  so,  for  in  a  hospital  is  found  the 
fullest  equipment  to  meet  these  emergencies, 
and  a  competent  surgeon  is  always  on  hand. 

The  commonest  and  perhaps  the  most  im- 
portant of  these  compound  fractures  are  man- 
gled and  lacerated  hands.  We  see  them  here 
daily,  and  I  am  able  to  show  you  now  a  man 
suffering  from  such  an  injury.  I  say  that  these 
accidents  to  the  hand  are  most  important  be- 
cause serious  crippling  or  loss  of  the  hand 
means  a  loss  of  livelihood  to  the  victim,  and  to 
the  surgeon  each  of  these  cases  means  a  fresh 
problem  of  very  great  interest.  Every  half 
inch  of  finger  saved  and  every  joint  restored  is 
of  importance.  Most  of  all  the  thumb,  that 
distinctive  mark  of  a  higher  evolution,  is  to  be 
preserved  if  possible.  The  thumb  without  the 
fingers  may  still  adorn  a  stump  capable  of  grasp- 
ing a  tool  and  doing  work,  but  a  hand  deprived 
of  the  thumb  is  a  very  futile  member. 

This  present  patient  is  a  machinist,  whose 
right  hand  was  caught  between  cog-wheels 
this  morning.  We  take  off  the  bloody  wrap- 
pings and  find  the  conditions  which  you  see  — ■ 
all  four  fingers  mangled  but  the  thumb  unin- 


ON   MINOR   SURGERY  53 

jured.  A  flap  of  skin  over  the  dorsum,  with 
its  pedicle  towards  the  wrist,  is  torn  up,  dis- 
closing the  second  and  third  metacarpal  bones, 
which  are  fractured.  The  whole  of  the  fore- 
finger is  mashed;  the  joints  opened  and  the 
distal  phalanx  wanting,  There  is  no  prospect 
of  saving  that  member,  but  the  other  fingers, 
though  lacerated,  may  be  saved,  I  believe. 
That  hand  means  a  study  in  reconstruction,  and 
perhaps  two  hours  of  painstaking  work  at  patch- 
ing and  mending.  Ether  and  asepsis  are  our 
first  steps,  and  those  of  you  who  will  sit  down 
here  with  the  house  surgeon  at  his  task  will  see 
the  exhaustive  care  he  puts  into  it.  All  bleed 
ing  is  checked,  every  torn  tendon  is  stitched 
and  replaced,  bits  of  destroyed  tissue  are 
trimmed  away,  hopelessly  comminuted  bone 
fragments  are  removed,  each  finger  is  treated 
as  a  separate  problem  and  given  its  appro- 
priate dressing,  skin  flaps  are  drawn  up  to 
cover  exposed  stumps  and  the  forefinger  is 
amputated  at  the  middle  of  the  first  phalanx. 
When  all  this  is  accomplished  satisfactorily 
the  hand  is  spread  out  upon  a  well-padded 
splint,  with  dry  gauzes  about  and  between  the 
fingers,  and  the  limb  to  the  elbow  is  put  up  in 
an  abundant  elastic-compression  dressing.  It 
is  very  important  in  this  case,  as  in  the  case  of 
the  man  with  a  cut  palm,  whom  I  showed  you 
at  our  first  exercise,  that    the   muscles  of  the 


54  CLINICAL   TALKS 

forearm  and  hand  be  immobilized  absolutely. 
We  must  have  no  dragging  on  these  freshly- 
united  tendons  and  delicate,  new  forming  tissues. 

Then  the  arm  is  supported  carefully  in  a 
sling  or  held  high  on  the  chest  in  a  Velpeau 
bandage.  If  all  goes  well  the  patient  may  ex- 
pect the  use  of  his  hand  by  the  end  of  two 
months,  but  we  can  give  him  no  such  positive 
assurance.  Skin  flaps  may  lose  their  vitality; 
bones  may  suffer  from  osteo-myelitis  and  be- 
come necrotic;  tendons  may  slough;  sinuses 
leading  to  deep-seated  inflammations  may  per- 
sist for  weeks,  and  many  and  various  minor, 
secondary  operations  may  be  necessary  before 
we  are  through  with  this  case.  But  the  great 
preliminary  care  is  worth  the  patient's  while, 
and  ours,  for  all  that.  With  it  we  can  promise 
him  a  useful  hand;  without  it  he  would  have 
to  expect  a  crippled,  helpless  claw. 

In  connection  with  this  subject  of  lacerated 
hands,  I  must  warn  you  that  you  will  find  the 
treatment  of  lacerated  feet  a  still  more  difficult 
matter.  It  is  not  because  there  is  anything 
peculiar  in  the  structure  of  the  feet,  but  because, 
owing  to  their  dependent  position,  their  circu- 
lation, except  in  the  case  of  the  young  and 
vigorous,  is  not  so  good  as  is  that  of  the  hands. 
That  you  must  always  bear  in  mind  if  you 
would  avoid  trouble  for  which  you  might  justly 
be  held  to  blame. 


ON  MINOR  SURGERY  55 

Take  two  similar  cases  —  a  man  with  a 
jammed  thumb  and  a  man  with  a  jammed  toe. 
You  dress  up  the  former  and  send  him  home, 
to  find  in  the  course  of  a  couple  of  weeks  that 
he  is  quite  well.  You  dress  the  man  with  the 
jammed  toe  and  send  him  off  about  his  busi- 
ness, and  what  do  you  find?  By  the  end  of 
two  weeks,  in  spite  of  oversight,  the  toe  is  far 
from  healed:  it  is  red,  tender,  and  slightly  sep- 
tic; the  whole  foot  is  swollen  and  tender,  and 
very  likely  there  is  a  bit  of  necrotic  phalanx  to 
be  felt.  This  untoward  result  is  due  to  no  lack 
of  aseptic  precautions  on  your  part,  but  to  the 
fact  that  you  have  failed  to  observe  our  second 
cardinal  principle  —  support.  You  cannot 
safely  send  these  patients  out  to  knock  about 
the  streets.  Either  they  must  be -put  to  bed 
with  the  leg  elevated  —  the  best  thing  by  far  — 
or  they  must  be  instructed  to  bear  no  weight 
on  the  foot  and  to  keep  it  up  on  a  chair  or  sofa 
except  when  necessarily  in  use.  The  point 
sounds  like  a  small  one,  but  it  is  salient. 

So  much  for  compound  fractures  —  perhaps 
the  most  important  division  of  traumatic  sur- 
gery. We  have  but  skirted  the  border  of  a 
great  subject,  but  sufficiently  near,  I  trust,  to 
show  that  here,  as  in  the  lesser  lesions  con- 
sidered, the  same  broad,  inevitable  principles 
constantly  must  be  applied. 


LECTURE    VI 

GRANULATING   WOUNDS    AND   VARICOSE  ULCERS 

Gentlemen :  There  exists  in  the  minds  of 
students,  and  often  of  graduates  as  well,  a 
confusion  regarding  ulcers  and  granulating 
wounds.  It  is  a  natural  confusion,  for  the 
two  conditions  overlap  and  run  into  each 
other.  An  ulcer  may  be  described  as  a  super- 
ficial solution  in  continuity,  which  shows  no 
tendency  to  heal;  a  granulating  wound,  as  a 
solution  in  continuity,  which  shows  a  tendency 
to  heal.  Of  course  such  a  definition  is  a  very 
general  one,  but  it  will  answer  our  present  pur- 
poses. You  may  see  many  examples  of  both 
lesions  in  this  clinic,  and  you  will  find  it  diffi- 
cult in  some  cases  to  decide  with  which  you  are 
dealing. 

Ordinarily,  however,  there  is  no  question 
when  you  are  dealing  with  a  granulating 
wound.  You  will  see  the  red  velvety  granu- 
lations shrinking  in  area  steadily,  with  little 
projections  of  new  skin  shooting  in,  and  the 
process   of  repair   so    constant   and  inevitable 

S6 


ON   MINOR  SURGERY  57 

that  you  can  appreciate  the  changes  from  day 
to  day. 

In  regard  to  such  a  healthy  granulating 
wound  there  are  two  questions  which  the  stu- 
dent is  always  asking  and  about  which  he 
seems  to  feel  that  he  gets  very  little  light. 
With  what  applications  shall  it  be  treated, 
and  how  often  shall  the  dressing  be  changed? 

Ordinarily  the  answer  to  that  first  question 
is  a  very  simple  one  when  the  wound  is  in  a 
healthy  individual.  Take,  for  instance,  the  case 
of  this  woman.  Her  breast  was  removed  for 
sarcoma  some  three  weeks  ago.  The  skin  flaps 
were  not  drawn  tightly  together  at  one  point, 
with  the  result  that  she  has  on  the  front  of 
the  chest,  as  you  see,  a  superficial  open  wound 
about  the  size  of  a  silver  dollar.  It  is  clean, 
fiat,  bright  crimson,  and  does  not  bleed  easily. 
It  will  heal  over  in  a  few  days,  no  matter  how 
you  treat  it,  provided  only,  and  this  is  impor- 
tant, provided  you  keep  it  clean.  You  can  wash 
it  with  corrosive  alcohol,  or  creolin,  put  on  a 
gauze  cocoon,  and  leave  it  for  three  or  four 
days.  When  she  comes  in  again  the  pad  will 
be  found  moistened  with  pus,  but  the  wound 
clean,  and  smaller  than  to-day.  Such  wounds 
as  this  require  no  special  care. 

On  the  other  hand,  take  this  case  of  a  granu- 
lating wound  on  the  back  of  the  neck  of  this 
man.      The  patient  is  fifty  years  old  and  has 


58  CLINICAL  TALKS 

two  per  cent  of  sugar  in  his  urine,  for  which 
he  is  under  treatment.  Two  weeks  ago  he 
came  in  here  and  showed  us  on  the  back  of  his 
neck  a  carbuncle  the  size  of  an  Enghsh  walnut. 
I  excised  cleanly  the  carbuncle,  and  so  stopped 
the  process.  There  has  been  no  return  of  the 
active  local  infection,  but  the  wound  has  not 
healed  readily.  The  raw  surface,  as  large  as 
the  top  of  an  egg  cup,  is  still  nearly  as  it  was 
two  weeks  ago.  The  granulations  are  dark 
purple,  soft,  spongy,  and  bleed  easily  when 
handled.  About  the  edges  they  overlap  in 
fringes.  That  overlapping  we  call  exuberant 
granulations;  it  is  a  perfectly  harmless  condi- 
tion and  is  easily  remedied.  That  is  the  con- 
dition known  to  the  laity  as  "proud  flesh,"  and 
is  always  referred  to  by  them  with  horror  — 
just  why  is  not  clear. 

There  are  various  methods  of  treating  such 
granulations,  but  all  methods  come  down  to 
this,  that  the  granulations  must  be  trimmed 
down  and  the  wound  stimulated  into  proper 
activity  so  that  it  shall  have  the  vigorous, 
healthy  appearance  which  we  saw  in  the  case 
of  the  woman.  With  the  scissors  I  cut  off 
these  redundancies,  —  they  are  absolutely  in- 
sensitive,—  and  after  checking  the  oozing  by 
sponge  pressure,  I  wipe  over  the  whole  wound 
with  the  stick  of  silver  nitrate.  Then  a  dry 
gauze   dressing   is   applied.      Every   other   day 


ON  MINOR  SURGERY  59 

the  man  will  return,  and  we  hope  soon  to  see 
the  wound  closing  in.  Another  excellent 
method  of  treating  this  wound,  after  trimming 
the  granulations,  is  to  dust  it  thickly  with  some 
simple  drying  powder,  such  as  dermatol  or 
aristol.  But  after  all,  what  you  must  bear  in 
mind  is  that  the  wound  is  to  be  kept  clean  and 
the  granulations  frequently  trimmed  down. 
Our  familiar  supporting  bandage  must  never 
be  omitted,  for  the  pressure  it  exercises  helps 
the  circulation  in  the  parts  and  prevents  passive 
congestion  and  stagnation. 

We  are  fortunate  to  have  another  patient 
here  who  presents  a  third  type  of  granulating 
wound.  He  is  a  boy  who  received  a  severe 
kick  on  the  shin  about  a  month  ago.  The 
perisoteum  and  bone  were  not  injured,  but  he 
showed  us  a  superficial  wound,  long  and  nar- 
row, as  though  you  had  torn  up  the  skin  for  a 
distance  of  five  inches  with  your  finger  nail. 
Three  weeks  ago  this  long,  narrow  wound,  in 
the  apparently  healthy  lad,  began  to  be  lined 
with  the  small,  flat,  dull,  red  granulations 
which  you  see,  and  thus  it  has  remained.  It 
refuses  to  heal.  It  has  been  scarified,  curetted, 
and  wiped  frequently  with  the  caustic,  but 
without  avail.  We  are  now  planning  to  have 
the  lad  get  out  into  the  country  to  see  what 
out-of-doors  life  will  do  for  him.  Meantime 
I  shall  dress  the  wound  daily  with  a  stimulating 


6o  CLINICAL   TALKS 

lotion  on  gauze  and  bandage  the  leg  from  toes 
to  mid-thigh. 

In  such  cases  you  will  find  diluted  tincture 
of  myrrh,  one  part  in  twenty  of  water,  or  pure 
balsam  of  copaiba,  to  be  excellent.  I  have 
always  been  pleased,  too,  with  the  action  of 
Gamgee's  favorite  application:  Borax,  i  part; 
compound  tincture  of  lavender,  8  parts;  glycer- 
ine, 4  parts;  water,  24  parts. 

Such,  briefly,  are  some  of  the  methods  of 
treating  these  open  wounds.  You  will  find 
in  the  books  and  be  told  by  doctors  of  innumer- 
able other  lotions,  ointments,  and  applications. 
Many  of  them  doubtless  are  useful,  certainly 
most  of  them  are  harmless;  but,  after  all,  what 
you  have  to  remember  is  to  keep  the  wound 
clean  and  give  nature  a  chance. 

In  this  connection  I  am  prompted  to  give 
you  a  word  of  advice.  You  will  come  to  find 
as  undergraduates,  and  later  as  graduates, 
that  there  is  a  common  tendency  among  certain 
men  to  sneer  at  measures  and  methods  with 
which  they  are  unfamiliar.  Against  such  men 
be  on  your  guard.  They  are  almost  as  danger- 
ous in  their  way  as  are  the  credulous  igno- 
rant. Their  opinions  are  not  founded  on 
reason,  but  on  sloth  and  indifference,  and  a 
certain  tired  skepticism  born  of  sad  experi- 
ence. But  theirs  is  not  the  truly  scientific 
spirit  which  waits    patiently   for  proofs.     The 


ON   MINOR  SURGERY  6i 

unreasoning  sceptics  are  prone  to  translate  an 
attitude  of  legitimate,  cautious  doubt  into  one 
of  bumptious  cynicism. 

Now  let  me  bring  before  you  another  class 
of  cases,  varicose  ulcers,  allied  to  granulating 
wounds,  cases  which  are  a  weariness  often  to 
students  and  dressers,  for  by  long  continuance 
they  become  an  opprobrium  to  these  clinics. 
Yet  they  should  not  be  a  bore.  These  ulcers 
are  very  grievous  afflictions  to  their  victims, 
they  belong  to  a  very  interesting  class  of  path- 
ological processes,  and  they  heal  under  proper 
treatment. 

For  hundreds  of  years  surgeons  have  talked 
and  written  about  varicose  ulcers,  and  the  opin- 
ions of  the  best  surgeons  regarding  their  nature 
and  treatment  have  always  been  correct,  yet 
even  to-day  you  sometimes  see  the  cases  drag 
on  an  interminable  course,  submitted  to  a 
treatment  which  is  amazing  and  discourag- 
ing. 

You  may  usually  tell  a  varicose  ulcer  at  a 
glance.  It  is  on  the  shin,  below  the  middle  of 
the  leg;  above  and  about  it  are  enlarged  super- 
ficial veins,  and  commonly  the  leg  is  swollen 
more  or  less.  In  few  lesions  is  the  cause  of  the 
trouble  as  obvious  as  in  these  ulcers.  Know- 
ing the  cause,  you  must  remedy  that,  and  in  so 
doing  attack  the  disease  at  its  source.  These 
ulcers  are  due  to  varicose  veins,  so  you  must 


62  CLINICAL  TALKS 

cure  the  varicose  veins,  or  at  least  you  must 
support  and  relieve  them. 

This  is  such  a  transparent  truism  that  it 
seems  as  though  it  should  be  apparent  to  the 
meanest  intellect,  yet  wise  men  are  seen  to  pass 
it  by.  Think  for  a  moment  of  what  the  process 
is.  First,  there  arises  the  dilatation  of  the 
veins,  a  condition  lasting  perhaps  for  years; 
gradually  as  the  walls  of  the  veins  become 
thinned  and  inelastic  and  their  valves  incom- 
petent, a  condition  of  stasis  results.  A  thin 
serum  oozes  out  into  the  surrounding  tissues 
and  causes  the  oedematous  swelling.  At  the 
same  time  there  is  an  exudation  of  red  blood 
corpuscles,  which  produce  an  extensive  pig- 
mentation of  the  skin,  associated  not  infre- 
quently with  an  eczema.  As  a  result  of  all 
this  the  nutrition  of  the  leg  is  greatly  impaired, 
and  the  ideal  conditions  favoring  an  inflamma- 
tory process  with  destruction  of  tissue  are 
present.  Sometimes  as  a  result  of  throm- 
bosis of  the  veins  and  malnutrition  of  the  sur- 
rounding parts,  a  phlebitis  or  a  periphlebitis 
is  seen;  there  may  even  be  rupture  of  a  vein 
with  serious  hemorrhage;  but  more  commonly, 
as  a  result  of  some  slight  blow,  or  even  scratch, 
a  superficial  skin  lesion  is  caused.  This  refuses 
to  heal  in  the  sodden  tissues,  bacteria  rush  in, 
and  a  destructive  ulcer  is  formed. 

It  is  for  this  ulcer  that  the  victim  seeks  advice 


ON  MINOR  SURGERY  63 

at  last.  He  seeks  advice,  and  I  regret  to  say 
that  he  sometimes  is  given  plasters  and  washes, 
ostensibly  for  the  eczema,  I  suppose.  With 
your  knowledge  of  the  cause  of  his  trouble 
you  will  say  that  such  treatment  is  preposter- 
ous. It  is  preposterous,  but  you  will  see  more 
than  one  patient  so  treated  hitherto,  come 
despairingly  into  this  clinic. 

Now  let  me  show  you  one  of  these  unfortu- 
nate patients.  He  is  a  man  of  forty-five ;  a  day 
laborer;  a  man  who  stands  constantly  on  his 
legs.  The  pain  of  his  disease  has  disabled  him 
utterly.  You  observe,  in  the  first  place,  the 
great  size  of  his  calves  and  feet.  He  is  not  a 
large  man;  he  weighs  perhaps  a  hundred  and 
sixty-five  pounds,  but  his  right  leg,  which  is 
the  seat  of  the  ulcer,  measures  twenty  inches. 
The  whole  leg  below  the  knee  is  of  a  dark  red- 
dish-brown color,  mottled  and  shiny.  There 
the  veins  are  disguised,  but  behind  the  knee 
in  the  popliteal  space,  and  along  the  course  of 
the  internal  saphenus  you  see  the  veins  stand- 
ing out  in  great  bunches.  Over  the  front  of 
the  shin  and  spreading  back  into  the  calf  is 
this  irregular  ugly  ulcer,  as  large  as  your  out- 
spread hand.  Its  edges  are  indurated  and 
elevated,  and  it  is  lined  with  sloughy,  dull  red, 
flabby  granulations.  As  the  man  says  truly,  it 
is  a  very  sore  leg. 

I  have  had  the  patient  lie  down  on  the  ex- 


64  CLINICAL  TALKS 

amining  table  for  half  an  hour,  with  his  leg 
supported  at  an  angle  of  forty-five  degrees. 
That  has  demonstrated  two  things.  It  has 
given  us  an  idea  of  the  extent  of  the  swelling, 
for  now  we  find  the  calf  to  measure  but  sixteen 
and  one-half  inches  in  circumference,  —  a 
shrinkage  of  three  and  one-half  inches,  —  and  it 
has  given  us  an  important  clue  as  to  treatment. 
Indeed,  it  has  brought  us  back  to  our  first 
principles,  and  shown  us  the  importance  of 
elevation  and  support.  For  let  me  tell  you 
that  the  method  by  which  most  quickly  to 
secure  a  healing  would  be  to  put  the  man  to 
bed,  to  bandage  properly  the  leg  and  swing  it 
in  a  hammock.  Thus  the  veins  would  be  kept 
constantly  emptied  by  the  action  of  gravity; 
the  circulation  would  be  quickened  and  the 
nutrition  re-established;  the  exudate  would 
be  absorbed  in  a  few  days  and  the  ulcer  would 
be  converted  into  a  granulating  wound. 

For  various  reasons  such  an  admirable 
method  of  treatment  may  not  be  instituted  in 
this  case,  so  we  must  adopt  the  next  best 
method,  and  on  the  whole  it  is  the  one  most 
practicable  in  such  cases. 

In  the  first  place,  when  there  is  any  con- 
siderable oedema  present,  I  always  order  the 
half  hour  of  elevation.  Thus  we  find  that  we 
have  to  deal  with  a  leg  of  a  more  nearly  normal 
size,  with  oedema  diminished  and  veins  emptied 


ON   MINOR   SURGERY  65 

of  their  accumulations.  Next,  to  clean  up  the 
sloughy  ulcer  with  its  indurated  border,  I 
apply  a  gauze  pad,  wrung  out  of  pure  glycer- 
ine, overlapping  the  edges.  The  glycerine 
acts  to  draw  out  the  serum  from  the  tissues 
and  rapidly  softens  the  indurations.  If  you 
choose  you  may  etherize  the  patient  and  curette 
the  ulcer  and  its  edges,  but  this  rarely  is  neces- 
sary. Then  from  toes  to  mid-thigh  I  apply 
firmly,  snugly,  and  with  uniform  elastic  com- 
pression our  wadding  rollers  of  many  thick- 
nesses and  a  cotton  bandage. 

Now,  whatever  position  the  patient  assumes, 
the  veins  cannot  again  become  distended,  the 
leg  cannot  swell,  and  the  nutrition  of  the  parts 
cannot  seriously  be  disturbed.  The  patient 
will  be  directed  to  keep  as  quiet  as  possible 
for  three  or  four  days  and  to  have  his  leg  up 
on  a  chair  most  of  the  time,  but  within  the  week 
he  will  go  back  to  work  in  some  degree  of  com- 
fort. To-morrow  he  will  return  to  have  the 
glycerine  pad  removed  and  the  bandages 
reapphed.  That  his  condition  will  then  be 
satisfactory   I   hope  to   show  you. 

Meantime  look  at  this  second  man,  who  is 
suffering  from  a  similar  ulcer  and  has  been 
under  treatment  since  the  day  before  yester- 
day. He  was  dressed  with  our  glycerine  pad 
and  supporting  bandage,  which  has  been  once 
renewed.     You  see  now  a  condition  very  differ- 


66  CLINICAL   TALKS 

ent  from  that  of  our  control  patient.  The  leg 
is  still  swollen  and  oedematous,  but  not  markedly 
so.  The  veins  are  inconspicuous,  and  the  ulcer 
itself,  instead  of  being  indolent  and  sloughly 
looking,  is  lined  with  red  and  fairly  healthy  gran- 
ulations ;  in  other  words,  it  is  taking  on  the 
characteristics  of  a  granulating  wound.  As  for 
further  treatment,  the  important  thing  is  to 
continue  our  support,  without  which  the  lesion 
would  quickly  relapse  into  an  ugly  ulcer.  To 
the  granulations  I  shall  apply  sterilized  absorb- 
ent gauze.  Nothing  else  is  needed,  and  by 
our  continuing  in  this  course  I  hope  to  show 
you,  within  three  weeks,  the  wound  nearly 
healed  and  the  man  going  about  in  normal, 
comfortable  fashion. 


LECTURE   VII 

FELON,    WHITLOW,    PARONYCHIA,    PALMAR 
ABSCESS 

Gentlemen:  You  will  find  it  hard  to  define 
the  first  three  words  which  give  a  title  to  this 
exercise.  Felon  and  whitlow  have  no  proper 
etymological  reason  for  existence;  paronychia 
is  derived  obviously  from  Uapd^  around,  and 
B  vwc,   nail;   palmar   abscess   is   self-evident. 

I  am  making  this  seemingly  needless  talk 
about  definitions  because  no  two  surgeons  will 
be  found  to  agree  about  the  meaning  of  those 
first  three  words,  and  even  the  medical  diction- 
aries are  at  loggerheads. 

Felon  means  one  guilty  of  felony,  a  wicked, 
cruel  person,  hence  the  word  has  been  applied 
to  a  cruel  infection.  Whitlow  means  literally 
a  white  flame;  ' '  a  painful  inflammation  tending 
to  suppurate,  in  the  fingers  or  toes."  ^  That 
seems  a  fairly  good  definition.  Very  many 
surgeons  regard  whitlow  as  identical  with  felon; 
I  do  so  myself,  and  as  I  find  no  great  authority 
or  even  well-established   custom  to  oppose  me 

^  Chambers'  Etymological  Dictionary. 
67 


68  CLINICAL  TALKS 

I  shall  continue  to  do  so.  Remember,  then,  that 
for  us  whitlow  and  felon  are  interchangeable 
terms. 

But  paronychia  —  there  is  our  rock  of 
offense,  for  fully  half  the  authorities  make  it 
identical  with  whitlow  and  felon. ^  So  we  are 
left  to  follow  our  own  fancies,  and  I  have  taken 
the  liberty  of  following  mine  so  far  as  definitely 
to  contrive  two  definitions  which  I  believe  to 
be  descriptive,  convenient,  and  fairly  accurate: 

As  whitlow  is  felon,  and  the  latter  word  is  in 
more  common  use,  I  shall  drop  the  term  "  whit- 
low." 

A  felon  is  an  acute  infection  of  the  finger 
(or  toe),  progressive,  with  a  tendency  to  involve 
the  bone. 

A  paronychia  is  an  acute  infection  of  the 
finger  (or  toe),  progressive,  situated  near  the 
nail,  which  it  tends  to  involve. 

Bear  in  mind  that  paronychia  may  spread 
further  and  involve  the  whole  finger  —  in 
which  case  it  should  more  properly  be  called  a 
felon.  And  bear  in  mind  also  that  the  great 
majority  of  felons  are  situated  over  the  terminal 
phalanx. 

*  Foster,  Dunglison,  Keating,  Gould,  and  Duane  group  felon, 
whitlow,  and  paronychia  under  one  head  and  call  the  hybrid 
affection  "  peri  phalangeal  abscess."  The  Century  Dictionary: 
"  Felon,  an  acute  and  painful  inflammation  of  the  deeper  tissues 
of  the  finger  and  toe,  especially  of  the  distal  phalanx;  generally 
seated  near  the  nail." 


ON   MINOR  SURGERY  69 

This  is  only  a  beginning  of  the  controversy. 
We  could  go  on  for  an  hour  juggling  terms  and 
disputing  as  to  what  does  or  what  does  not 
constitute   felon. 

Conceive,  then,  of  felon  as  an  acute,  progres- 
sive infection,  situated  anywhere  on  the  finger. 
It  may  be  superficial,  it  may  be  deep,  it  may 
be  both  superficial  and  deep.  Take  that  last 
conception  as  an  example  of  a  common  form 
of  felon  and  examine  the  finger  of  this  woman. 

One  week  ago,  as  she  tells  us,  she  pricked  her 
finger  with  a  carpet  tack.  The  little  wound 
healed  apparently,  but  after  three  days  the 
end  of  the  finger  became  red  and  the  skin  over 
the  pulp  elevated,  somewhat  in  the  form  of  an 
ordinary  blister.  But  there  was  pain  and 
there  is  pain  now  —  throbbing,  wearing  pain. 
I  tie  a  rubber  tourniquet  about  the  base  of  the 
finger  and  inject  a  few  drops  of  two  per  cent 
cocaine  along  the  course  of  each  lateral  nerve. 
Then  with  the  scissors  I  trim  off  the  blister. 
That  leaves  us  with  a  red,  mottled  surface  about 
the  size  of  a  silver  dime.  It  looks  like  a  gran- 
ulating area.  All  the  sero-pus  contained  in 
the  blister  has  been  evacuated,  and  you  would 
suppose  that  here  was  an  end  of  the  affair.  If 
now  I  take  the  finger  in  my  hand  and  gently 
squeeze  it  you  see  a  minute  drop  of  pus  exude 
slowly  from  a  point  in  the  granulations.  That 
means  that  there  is  a    little  track  connecting 


70  CLINICAL   TALKS 

the  superficial  cavity  we  have  opened  with  a 
deeper  cavity.  This  felon  is  a  compound 
affair,  with  two  pus  chambers  in  tiers,  one  above 
the  other.  They  are  connected  by  the  minute 
channel  which  was  perhaps  the  original  track 
of  the  carpet  tack  or  maybe  was  caused  by  the 
inflammatory  action  itself. 

This  form  of  felon  with  its  two  chambers  has 
been  felicitously  termed  a  "shirt-stud  abscess." 
There  may  be  two  or  more  connecting  channels, 
but  the  name  is  just  as  good.  So,  when  you 
open  a  superficial  felon,  remember  that  a  felon 
is  progressive,  and  search  for  that  second  cham- 
ber. Now  I  open  the  deeper  pocket,  of  course, 
and  find  myself  on  the  periosteum.  I  clean 
out  the  little  cavity;  wipe  it  thoroughly  with 
peroxide  of  hydrogen,  lay  in  it  gently  a  bit  of 
absorbent  tape,  wrap  the  finger  in  a  hot  creolin 
poultice,  bandage  the  hand  and  forearm  with 
elastic  compression,  and  suspend  them  in  a 
sling. 

In  this  place  let  me  say  one  word  about  poul- 
tices. They  have  been  used  from  time  imme- 
morial for  the  comfort  they  bring  to  the  affected 
part.  Their  action  is  to  stimulate  the  super- 
ficial circulation,  and  thus,  by  relieving  con- 
gestion, to  check  inflammatory  action  and  allay 
pain.  Such  a  use  of  poultices  is  as  comforting 
to-day  as  ever  it  was. 

A  poultice  must  supply  heat  and  moisture; 


ON    MINOR   SURGERY  71 

deprived  of  either  it  is  no  longer  a  poultice. 
The  materials  of  which  poultices  have  been 
made  are  many,  but  mostly  surgeons  have  tried 
to  employ  some  vehicle  which  would  retain 
heat.  Such  a  vehicle  is  found  in  Indian  meal, 
flaxseed  and  the  various  cereals.  They  remain 
moist  and  warm  for  a  long  time,  but  they  are 
beautiful  culture  media.  For  a  vigorous  in- 
fection-spreading agent,  recommend  me  to  the 
old-fashioned  bread  and  milk  poultice. 

With  Listerism  there  came  in  the  so-called 
antiseptic  poultice.  As  commonly  used  it  is 
not  antiseptic.  The  best  that  can  be  said  of  it 
in  that  regard  is  that  it  is  aseptic.  When 
properly  prepared  it  is  a  useful  dressing,  because 
it  is  sterile  and  because  by  supplying  heat  and 
moisture  it  stimulates  the  reparative  processes. 
Then,  too,  it  is  easily  applied. 

So  you  see  that  in  the  use  of  the  properly 
constructed  and  apphed  poultice  we  return 
again  to  our  first  principles  —  we  support  the 
part  and  we  stimulate  and  equalize  the  circu- 
lation. 

That  form  of  antiseptic  poultice  which  I  pre- 
fer is  made  of  sheet  wadding  pads  wrapped  in 
absorbent  gauze  and  covered  with  some  water- 
proof material  like  oiled  silk  or  parchment 
paper.  The  pads  are  wrung  out  of  a  hot  creolin 
solution,  one  in  two  hundred.  You  may  use 
bichloride  or  boric  acid,  but  carbolic  acid  never. 


72  CLINICAL   TALKS 

The  poultices  should  do  much  more  than  cover 
the  affected  region  only.  If  the  whole  finger 
is  involved,  wrap  the  hand;  if  the  hand  is  in- 
volved, include  the  forearm  in  the  poultice. 
Thus  you  will  quiet  the  adjacent  muscles  and 
protect  the  efferent  lymphatics.  It  is  well 
also  to  put  on  a  light  splint  outside  of  the  poul- 
tice for  more  perfect  immobilization. 

Then  as  to  the  drainage  of  these  abscesses  — ■ 
gauze  wicking  is  usually  sufficient.  Do  not 
pack  the  cut  with  gauze.  That  will  cork  up 
the  pus.  Gauze  packing  is  never  used  except 
to  check  hemorrhage.  To  drain,  lay  gently 
into  the  cut  one  or  two  wicks  or  tapes.  These 
will  carry  off  by  capillarity  the  secretions  and, 
being  interposed  between  the  cut  edges,  will 
prevent  a  superficial  gluing  together  of  the 
skin  wound  and  a  consequent  pocketing  and 
burrowing  of  pus  in  the  deeper  parts. 

To  demonstrate  further  the  treatment  of 
felons  let  me  show  you  a  second  case.  This 
man  has  been  aware  of  a  throbbing  pain,  in- 
creasing in  severity,  for  the  past  four  days, 
over  the  middle  phalanx  of  his  ring  finger. 
The  primary  cause  of  the  trouble  is  unknown 
to  him.  You  will  observe  that  the  whole 
finger  is  hot  and  swollen,  and  on  compressing 
between  your  thumb  and  finger  the  lateral 
vessels  on  either  side  of  his  finger  you  plainly 
feel  them  throbbing.     That  is  a  distinctive  and 


ON   MINOR   SURGERY  73 

interesting  point  in  the  diagnosis  of  localized 
inflammations  of  this  type.  You  will  not  dis- 
cover that  pulse  in  the  case  of  sprains  or  rheu- 
matoid affections.  This  man's  finger  is  not 
only  swollen  throughout,  but  its  palmar  skin 
is  reddened,  elevated,  and  excessively  tender. 
Feel  carefully  in  his  axilla,  and  you  detect  an 
enlarged  and  painful  gland.  His  body  tem- 
perature is  not  elevated,  his  pulse  is  not  rapid, 
nor  is  there  a  noteworthy  leucocytosis,  —  the 
white  count  being  9,000;  but  he  is  tired  from 
loss  of  sleep  and  weary  with  the  constant  pain. 
On  carrying  my  knife  deeply  down  through  the 
skin  and  laying  bare  the  tendon  sheath,  I  give 
vent  at  first  to  an  abundant  bloody  oozing, 
which  is  good.  Then  there  follow  half  a  dozen 
drops  of  pus,  in  which  you  will  probably  find 
streptococci  in  pure  culture.  If,  now,  I  content 
myself  with  this  cut  and  apply  my  dressing, 
to-morrow  may  show  us  the  superficial  parts 
mostly  glued  together.  That  is  a  condition 
we  do  not  want,  for  the  wound  must  be  made 
to  heal  by  granulation  from  the  bottom.  To 
favor  such  healing,  trim  off  the  skin  edges  so 
that  they  cannot  readily  be  brought  together 
—  a  simple  and  very  useful  manoeuvre.  Now 
we  apply  the  poultice,  light  splint,  bandage,  and 
sling. 

Properly    the     poultice    should    be    changed 
twice  a  day  at  least,  and  by  the  fourth  day  we 


74  CLINICAL  TALKS 

should  begin  to  see  a  clean,  granulating  wound. 
The  man  will  have  pain  to-night  probably,  and 
may  need  a  small  dose  of  morphia.  A  certain 
amount  of  pain  nearly  always  follows  a  cocaine 
operation  on  a  felon,  but.  by  to-morrow  he 
should  be  in  comfort. 

These  two  cases  have  been  very  simple  ones, 
but  all  felons  are  by  no  means  so  easy  of  treat- 
ment. The  pus  burrows;  tendons,  bones  and 
joints  are  involved;  slashing  incisions  and  am- 
putations may  be  necessary,  and  at  the  best 
some  impairment  of  function  is  very  apt  to 
ensue.  Such  results  you  shall  see  daily  in  this 
clinic.  The  therapeutic  measures  to  be  applied 
differ  in  degree  only  from  those  you  have  seen 
this  morning.  Pus  is  to  be  sought  out,  drain- 
age is  to  be  maintained,  asepsis  and  support 
are  vigorously  to  be  enforced,  pain  is  to  be 
relieved  and,  always,  the  general  condition  of 
the  patient  is  to  be  considered  and  strength- 
ened so  far  as  well  may  be. 

You  must  look  now  at  this  third  patient, 
who  very  conveniently  presents  us  with  an 
example  of  paronychia.  In  the  limited  sense 
in  which  we  use  the  term,  "  paronychia"  is  the 
common  nursery  "run-round."  This  child, 
who  brings  it  for  our  inspection,  pulled  a  hang- 
nail a  few  days  ago  until  she  drew  blood,  and 
so  infection  entered  in.  Day  before  yesterday 
the  skin  about  the  base  of  the  nail  was  reddened 


ON  MINOR  SURGERY  75 

and  painful,  forming  a  crescentic  swelling.  To- 
day there  is  pus  obviously  present,  for  it  shows 
creamy  through  the  thin  pellicle. 

There  is  a  common  way,  a  common  but  wrong 
way,  of  opening  these  little  abscesses.  That 
wrong  way  is  to  cocainize  the  finger  and  draw 
the  knife  in  a  semi-circle  through  the  skin  about 
the  base  of  the  nail.  So  you  will  evacuate  the 
pus,  but  you  will  have  left  an  ugly  sore,  with 
the  underlying  nail  at  the  bottom,  to  granulate 
slowly  up. 

Here  is  a  better  way.  I  lay  this  narrow- 
bladed  knife,  flat  upon  the  nail  with  the  knife 
point  against  the  inflamed  skin,  and  by  a  little 
gentle  prying,  which  should  be  painless,  I  insert 
it  along  the  skin  edge  and  the  base  of  the  abscess, 
I  withdraw  the  point,  when  you  see  it  followed 
by  a  jet  of  pus.  By  a  little  manipulation  the 
cavity  is  now  evacuated,  and  a  poultice  is  ap- 
plied. Unless  the  nail  and  matrix  have  be- 
come involved  in  the  inflammation,  sound 
healing  should  now  be  a  matter  of  two  or  three 
days  only. 

That  was  the  simplest  form  of  paronychia. 
If  you  carry  away  with  you  to-day  no  other  infor- 
mation than  of  the  little  trick  of  opening  it 
along  the  nail,  your  hour  has  not  been  wasted. 

As  in  the  discussion  of  felons,  so  here,  I  have 
scarcely  more  than  touched  upon  the  subject. 
This  process  may  rapidly  invade  the  flnger.     It 


76  CLINICAL  TALKS 


>■ 


may  attack  and  destroy  nail  and  matrix,  and 
involve  periosteum,  bone,  joint,  and  tendon. 
There  is  no  limit  to  its  possible  ravages,  but  for 
the  avoidance  of  confusion,  as  I  told  you  at  the 
first,  when  the  inflammation  has  passed  beyond 
the  region  of  the  nail,  I  prefer  to  speak  of  it  as 
felon  and  not  as  paronychia. 

Palmar  abscess  is  the  third  subject  to  be 
considered  to-day.  To  it  felon  and  paronychia 
naturally  and  inevitably  kad.  It  is  a  lesion 
of  great  interest, —  in  its  pathology,  its  treat- 
ment, and  its  capacity  for  far-reaching  damage. 
In  it  the  infection  usually  starts  in  the  palm, 
but  it  may  begin  in  one  of  the  fingers  and  spread 
to  the  palm. 

The  methods  of  infection  are  therefore  various, 
but  perhaps  the  commonest  method  is  that 
presented  by  the  hard-working  man  whom  I 
show  you.  He  is  a  gardener.  His  hand  bears 
heavy  callosities,  which  have  become  so  hard 
as  to  press  upon  and  irritate  the  underlying 
soft  structures.  This  bruising  has  caused  a 
considerable  blister,  which  has  become  infected 
from  the  overlying  skin,  and  in  turn  has  passed 
on  its  irritating  properties  to  the  deeper  parts. 

As  you  look  at  the  hand  it  appears  every- 
where swollen  —  back  as  well  as  front.  That 
puffy,  reddened  dorsum  is  swollen  from  oedema. 
If  you  were  to  cut  into  it,  you  would  draw  only 
serum  and  blood.     But  the  palm  shows  a  condi- 


ON   MINOR  SURGERY  77 

tion  quite  different.  It  is  not  so  greatly  dis- 
tended in  appearance  as  is  the  dorsum,  for  its 
deep  structures,  bound  down  by  the  dense 
palmar  fascia,  cannot  greatly  swell.  The  pain 
is  there,  however;  and  it  is  all  the  more  severe 
because  the  fascia  does  so  limit  the  swelling. 
In  order  to  escape  without  our  aid  the  pus  must 
burrow  up  under  the  annular  ligament,  into  the 
forearm,  and  that  is  what  we  fear.  So  you  see 
the  palm  of  the  hand  to  be  tense,  brawny,  but 
not  greatly  swollen.  It  is  exquisitely  sensitive 
to  pressure.  The  pus  must  be  let  out  quickly, 
and  here  again  we  are  presented  with  a  problem 
which  is  rendered  interesting  by  reason  of  ana- 
tomical complications.  No  other  region  of  the 
body  contains  so  many  and  such  diverse  struct- 
ures compressed  into  so  small  an  area.  There 
is  here  a  labyrinth  of  tendons,  nerves,  vessels, 
and  fasciae  —  to  say  nothing  of  tendon  sheaths, 
small  muscles,  and  bones.  All  these  structures 
are  essential  to  the  proper  use  of  the  hand  — 
that  wonderful  piece  of  mechanism.  We  cannot 
go  roughly  slashing  into  it  without  crippling  it, 
yet  to  get  out  the  pus  we  must  in  a  fashion 
slash. 

It  used  to  be  taught  as  a  safe  rule,  and  those 
who  so  taught  were  in  the  main  correct,  that 
when  cutting  into  the  palm  you  should  make 
your  incisions  short,  multiple,  and  parallel  to 
the  bones,  thus  avoiding,  so  far  as  possible,  the 


7^  CLINICAL  TALKS 

delicate  structures  of  the  hand.  That  plan  is 
not  a  bad  plan  —  indeed,  it  is  the  one  commonly 
followed  still,  but  it  has  this  disadvantage,  that 
through  these  straight  incisions  the  pus  is  sought 
somewhat  blindly  and  with  difficulty,  and  that 
the  incisions  tend  to  early  closure,  thus  damming 
in  the  discharges  and  necessitating  a  second 
operation  often.  Moreover,  such  wounds  heal 
with  disabling  scars,  which  are  bound  closely 
to  the  underlying  parts  and  seriously  limit  mo- 
tion. 

My  colleague.  Dr.  Brooks,  has  devised  an 
incision  which  I  prefer.  The  patient  is  now 
etherized.  While  his  hand  is  held  firmly  out- 
spread I  outline  a  semi-circular  flap  which  in- 
cludes the  whole  of  the  palm  practically.  I  enter 
the  knife  over  the  second  metacarpo-phalangeal 
joint,  as  you  see,  and  after  sweeping  round  the 
palm  I  bring  it  out  at  the  base  of  the  thenar  emi- 
nence; in  other  words,  the  flap  is  to  be  turned 
back  on  the  thumb  as  a  pivot.  Rapidly  dissect- 
ing away  the  skin,  I  have  now  exposed  completely 
the  palmar  fascia.  You  see  a  little  pus  oozing 
through  it  at  these  three  openings.  I  now  en- 
large the  openings  with  a  blunt  scissors  and 
rapidly,  without  damage  to  structure,  follow  up 
and  clean  out  all  the  cavities.  You  see  I  have 
had  to  deal  with  a  really  beautiful  and  well- 
exposed  dissection  of  the  palm,  I  have  avoided 
easily  the  important  arteries,  nerves  and  ten- 


ON   MINOR   SURGERY  79 

dons,  for  I  have  seen  them;  and  I  have 
searched  out  the  burrowing  pus  far  more  thor- 
oughly than  was  possible  by  the  old  blind 
method.  Now  I  disinfect  carefully  the  whole 
hand. 

How  about  drainage  and  the  after-treatment? 

Wicks  are  led  out  from  all  the  pockets;  a  thin 
layer  of  gauze  is  spread  over  the  whole  exposed 
surface  and  the  skin  flap  is  laid  back  over  the 
gauze.  In  the  subsequent  dressings,  when  neces- 
sary, the  skin  flap  may  again  be  turned  aside 
and  the  depths  of  the  wound  may  again  easily 
be  explored.  Judging  by  experience,  we  should 
find  the  inflammation  subsiding  in  a  day  or  two, 
when  the  wicks  gradually  will  be  removed.  By 
the  end  of  a  week  the  palm  and  the  under  surface 
of  the  flap  will  be  covered  with  granulations. 
Then,  if  all  looks  clean  and  sound,  we  shall  stitch 
the  skin  back  into  place  and  look  for  a  rapid 
healing  by  a  delayed  first  intention.  To  facili- 
tate the  sewing  back  of  the  flap  we  usually  pass 
these  so-called  provisional  stitches  at  the  time 
of  the  original  operation.  When  the  time  comes 
they  will  be  tied. 

For  the  first  four  or  five  days  it  is  well  to 
dress  the  hand  and  forearm  in  a  large  creolin 
poultice  with  a  splint,  but  this  may  be  abandoned 
soon  for  the  gauze  dressing  with  elastic  com- 
pression and  elevation. 

You  will  be  surprised  to  see  how  useful  and 


8o  CLINICAL   TALKS 

comely  a  hand  will  result  from  all  this.  The 
scar  will  be  there,  of  course,  but  it  will  not  be 
especially  troublesome,  and  the  function  of  the 
hand  will  generally  be  much  better  than  was 
the  case  when  multiple  linear  incisions  were 
used. 

Again,  let  me  warn  you,  in  closing,  that  in 
spite  of  what  I  have  said  of  your  flap  at  the 
thenar  eminence  you  must  never  operate  by 
rule  of  thumb.  Broadly  this  operation  is  a  good 
operation,  but  diverse  conditions  will  present 
themselves.  No  two  cases  are  alike,  and  while 
you  must  strive  always  to  observe  general 
principles,  you  must  apply  also  a  broader  com- 
mon sense. 


LECTURE   VIII 

BOIIS,     CARBUNCLES 

Gentlemen:  The  treatment  of  boils  may  seem 
to  you  a  very  minor  part  of  Minor  Surgery,  yet 
there  are  few  curable  conditions  more  trouble- 
some than  furunculosis. 

Last  winter  there  came  to  see  me  a  man  who 
is  the  chief  of  police  in  a  neighboring  town.  He 
had  upon  the  back  of  his  neck  two  boils  and  the 
scars  of  half-a-dozen  others.  For  four  months 
he  had  been  suffering  from  these  pests,  —  in 
constant  discomfort  with  a  sore  and  painful 
neck;  his  sleep  broken,  his  appetite  impaired, 
and  his  health  becoming  undermined.  On 
inqtiiry  I  learned  that  he  had  gone  ten  years 
without  a  day's  vacation,  and  that  for  six  months 
before  the  appearance  of  his  boils  he  had  been 
feeling  run  down  and  debilitated  from  that  con- 
dition of  faulty  metabolism  which  we  call 
muscular  rheumatism. 

I  gave  him  a  simple  cleansing  wash  for  the 
neck  and  a  course  of  aperient  waters.  I  en- 
joined a  two  weeks'  vacation  and  the  follow- 
ing   tonic:   sulphate    of    iron    3ii,    sulphate    of 

8i 


82  CLINICAL  TALKS 

magnesia  5vi,  dilute  sulphuric  acid  5vi,  syrup 
of  ginger  5iv,  water  Six,  —  a  combination 
which  I  borrowed  from  Dr.  L.  D.  Bulkley, 
and  have  found  very  useful  in  such  conditions. 
The  dose  is  one  teasponful  in  water  after  meals. 
To  the  boils  I  applied  merely  a  soft  protective 
cotton  dressing.  Ten  days  later  the  man 
wrote  to  me  that  his  boils  had  disappeared  and 
that  he  was  feeling  well. 

That  case  illustrates  one  of  the  most  impor- 
tant points  I  have  to  make  for  you  in  this  con- 
nection. It  is  the  point  I  have  so  often  made 
for  you  before.  You  must  regard  your  patient's 
general  condition.  And  boils  are  usually  a 
manifestation  of  a  general  condition.  They 
indicate  some  form  of  malnutrition  aud  must 
be  treated  on  that  basis. 

Billings'  Dictionary  defines  a  boil  as  "a  pain- 
ful conical  or  rounded  swelling  of  the  skin,  due 
to  inflammation  about  a  hair  follicle,  a  Mei- 
bomian gland,  or  a  sweat  gland."  That  is  a 
fair  enough  definition,  and  if  you  will  turn  to 
page  172  of  your  Warren's  "  Surgical  Pathology" 
you  will  find  the  nature  of  the  process  ex- 
haustively described.  The  point  of  it  all,  so 
far  as  the  clinician  is  concerned,  is  that  the 
organisms  normally  present  in  the  skin  gain 
lodgment  in  some  of  the  glands  or  ducts  and 
then  multiply.  The  active  development  of 
these  colonies  of  bacteria  produces  small  areas 


ON    MINOR    SURGERY  83 

of  connective  tissue  necrosis.  This  necrotic 
portion  acts  as  a  foreign  body,  and  nature  pro- 
ceeds to  throw  it  off  as  a  "core."  The  process 
of  throwing  it  off  gives  rise  to  further  inflam- 
mation, with  the  resulting  pus  formation  and 
swelling.  After  the  core  is  thrown  off  there 
remains  a  little  pit,  which  must  heal  by  granu- 
lation. So,  you  see,  there  are  three  stages 
in  the  life  history  of  a  boil,  and  each  stage 
demands  its  appropriate  treatment.  There 
is  the  first  stage,  when  we  see  only  a  small 
superficial  pustule;  the  second  stage,  when  we 
see  a  much  larger  mass  —  elevated,  indurated, 
and  painful,  containing  its  core;  and  the  third 
stage  of  a  craterlike  but  subsiding  swelling. 

Most  commonly  a  patient  comes  to  you  with 
a  well-developed  boil  in  the  second  stage  and, 
in  the  neighborhood,  two  or  three  incipient 
boils  or  pustules.  If  the  case  is  a  chronic  one, 
make  up  your  mind  about  the  patient's  general 
condition,  especially  as  regards  diabetes  and 
rheumatism. 

This  young  man  before  us  is  a  good  example 
of  what  I  am  describing.  He  is  a  night  watch- 
man, whose  daytime  sleep  is  disturbed.  He 
is  given  to  rather  excessive  whiskey  drinking, 
and  is  feeling  pretty  well  done  up.  He  has  a 
poor  appetite,  constipation,  a  furred  tongue, 
and  is  a  striking  type  of  the  tired  man  who  is 
burning  the  candle  at  both  ends.     I  need  not 


84  CLINICAL    TALKS 

trouble  you  with  details  of  general  treatment 
in  his  case  except  to  say  that  I  shall  stop  his 
liquor,  and  give  him  a  course  of  Carlsbad  salts, 
with  five  grains  of  Blaud's  pill  before  his  meals. 
Look  now  at  the  back  of  his  neck.  Here  on 
the  right  side  is  a  conical  swelling  the  size  of  a 
silver  "quarter."  It  is  reddened  at  the  center, 
where  it  is  beginning  to  break  down  and  soften, 
but  everywhere  else  it  is  indurated.  It  is  very 
tender  to  the  touch,  painful  on  pressure,  and 
he  says  it  "feels  sore  all  round."  To  the  left 
of  it  are  these  three  little  pustules,  with  red- 
dened areolae,  each  about  half  the  size  of  your 
little  finger  nail.  In  the  first  place,  as  regards 
these  incipient  boils,  let  me  tell  you  with  much 
assurance  that  they  may  be  aborted.  The 
old-fashioned  method  was  to  poultice  the  back 
of  the  neck  and  bring  the  whole  crop  to  a  head. 
Don't  do  it.  There  are  scoffers  who  will  tell 
you  that  boils  cannot  be  aborted.  I  doubt  if 
they  have  tried  faithfully  any  method.  Here 
are  two  methods.  You  may  prick  the  little 
pustule  and  wipe  out  the  minute  cavity  with 
a  probe  dipped  in  pure  carbolic  acid.  That 
often  will  suffice,  but  I  have  not  found  it  so 
successful  as  the  hypodermic  injection  of  very 
small  quantities  of  some  strong  antiseptic. 

In  the  first  place  I  cleanse  this  neck  with 
soap  and  water  and  alcohol.  Then  I  inject 
five  or  six  minims  of  cocaine,  in  four  per  cent 


ON   MINOR   SURGERY  85 

solution,  under  the  infected  areas.  Now  into 
this  ansesthetized  zone,  along  the  cocaine 
track,  I  inject,  under  each  pustule,  two  minims 
of  pure  styron,  —  an  ancient  but  efficient  bal- 
samic antiseptic.  I  prefer  it  to  carbolic  acid, 
because  more  thoroughly  it  permeates  the 
affected  tissues.  The  result  of  this  injection 
is  to  destroy  the  active  bacteria  and  to  convert 
the  infected  area  into  an  aseptic  eschar.  The 
immediate  result,  so  far  as  the  patient  is  con- 
cerned, is  that  the  sense  of  burning  and  discom- 
fort disappears  in  a  few  minutes;  without  fur- 
ther sensation  the  eschar  will  be  thrown  off  and 
the  little  wound  will  heal  up.  Remember  to 
use  cocaine  before  these  injections  of  styron,  for 
the  styron  used  without  such  preliminary  treat- 
ment causes  a  few  moments  of  very  severe  pain. 
I  am  satisfied  from  a  fairly  wide  experience 
with  this  method  of  aborting  boils  that  it  will 
usually  be  found  successful.  A  young  man 
came  to  me  last  winter  who  had  pustule  after 
pustule  appear  on  his  neck  for  a  period  of  sev- 
eral weeks.  Before  I  saw  him,  one  of  them 
had  got  ahead  of  us.  It  ran  a  severe  course  and 
had  to  be  opened  and  curetted  twice.  Into 
the  other  incipient  furuncles,  —  perhaps  a 
dozen  or  more,  as  they  appeared  from  week  to 
week,  —  I  injected  styron  and  checked  them  at 
once.  Finally  with  tonics  and  general  treat- 
ment the  malady  subsided. 


86  CLINICAL  TALKS 

There  is  another  method  of  treatment  which 
our  next  patient  illustrates.  He  is  a  medical 
student  who  kindly  offers  himself  for  our  in- 
struction. Two  months  ago  he  had  a  slightly 
septic  finger,  which  healed  without  trouble, 
but  he  became  "run  down  "  and  developed  a 
crop  of  boils  on  his  left  arm.  They  were  treated 
by  his  friends  and  the  surgeons  in  various 
dispensaries,  where  he  kept  at  his  work.  They 
were  opened,  injected,  poulticed,  time  after 
time,  but  continually  recurred  until  he  became 
discouraged  and  his  life  became  a  burden.  I 
had  seen  him  several  times,  but  was  unable  to 
check  the  process,  and  there  seemed  to  be  noth- 
ing for  it  but  to  send  him  away  on  a  long  vaca- 
tion. 

About  ten  days  ago  when  he  came  here  to 
consult  me  I  determined  to  take  a  leaf  from  the 
book  of  my  friend  Dr.  Burrell  and  try  the  effect 
of  a  carefully  applied  Gamgee  dressing.  At 
that  time  the  forearm  had  on  it  three  incipient 
boils  and  the  healing  scars  of  a  half-dozen 
others.  The  arm  was  carefully  disinfected, 
wrapped  in  absorbent  gauze,  and  put  up,  from 
fingers  to  shoulder,  in  our  wadding  and  mill- 
board apparatus  with  firm  compression.  A 
sling,  of  course,  completed  the  equipment. 

That  dressing  was  put  on  one  Friday  and 
remained  undisturbed  until  the  following  Tues- 
day.    I  then  removed  it,  to  find  the  arm  clean 


ON   MINOR   SURGERY  87 

and  shrunken,  the  little  red  boils  shriveled, 
and  the  old  scars  practically  sound.  As  you 
see  to-day,  the  patient  is  entirely  well,  no  new 
trouble  having  appeared  in  the  past  week.  I 
shall  now  allow  him  the  free  use  of  his  arm. 
That  was  an  interesting  experiment,  and  cer- 
tainly it  shows  in  a  most  striking  manner  the 
ever-present  value  of  our  familiar  first  principles 
—  support,  immobilization,  elevation. 

When  a  boil  has  developed  fully,  or  "come 
to  a  head  "  as  the  saying  is,  the  treatment  is 
very  simple  and  obvious.  There  is  then  no 
special  interest  in  it.  You  must  open  it  and 
clean  it  out.  Cocainize  it  first,  of  course,  by 
one  or  two  deep  injections  along  its  borders. 
You  may  make  a  conical  incision  or,  what  is 
better,  you  may  excise  a  little  cone  at  its  apex, 
about  half  as  large  as  a  silver  dime.  This  excis- 
ion will  usually  bring  with  it  the  core.  Then 
scrape  the  cavity  clean  and  drain  it  with  a  bit 
of  gauze.  For  a  day  or  two  a  creolin  poultice 
will  be  a  great  comfort  to  the  patient;  after 
that,  until  the  wound  is  healed,  our  cotton 
dressing  is  convenient  and  comfortable.  One 
little  note  here  —  never  plaster  a  cotton  dress- 
ing down  with  adhesive  strapping.  It  is  dirty 
and  ineffective,  compared  with  collodion,  and 
the  taking-off  process  is  painful.  The  collo- 
dion dressing  may  always  easily  be  soaked  off 
with  alcohol. 


88  CLINICAL  TALKS 

You  will  be  told  of  sundry  other  methods  of 
dealing  with  boils.  One  man  will  pin  his  faith 
to  internal  medication  and  ointments  and  an- 
other to  poultices  and  the  knife,  but  the  fact 
is  that  you  must  treat  each  individual  lesion 
according  to  the  indications  of  the  case.  When 
you  have  had  one  or  two  boils  yourselves  you 
will  have  had  a  valuable  lession.  Here,  as 
elsewhere  in  the  practice  of  our  art,  remember 
that 

"  He  jests  at  scars  that  never  felt  a  wound." 

When  we  come  to  deal  with  carbuncles,  we 
have  a  quite  different  problem  on  our  hands  — ■ 
different  in  the  extent  and  gravity  of  the  proc- 
ess, but  not  so  very  different  in  its  causation 
and  development. 

Let  me  ask  you  in  the  first  place  to  look  at 
these  two  patients,  who  present  us  with  car- 
buncles in  two  stages. 

The  first  patient,  a  woman,  has  here  below 
the  occipital  protuberance,  and  above  the  line 
of  her  hair,  a  conical  swelling  about  the  size  of 
a  silver  dollar.  As  I  part  the  hair  and  expose 
the  swelling  you  notice  that  its  apex  has  an 
excoriated  look  and  that  there  are  three  little 
craters  from  which  a  drop  or  two  of  pus  may 
be  squeezed.  The  little  mass  is  brawny  to 
feel  and  is  quite  deeply  seated.  Take  it  as  a 
whole,  however,  it  resembles  closely  a  boil,  and 


ON  MINOR  SURGERY  89 

you  might  readily  mistake  it  for  one.      It  is  a 
carbuncle  in  its  early  stages. 

In  comparison,  the  process  in  this  man  is 
much  farther  advanced.  It  is  in  the  common 
location  on  the  back  of  the  neck,  on  the  left 
side,  below  the  line  of  the  hair,  and  to  look  at 
appears  to  be  as  large  as  the  top  of  a  small  tea- 
cup; when  you  come  to  handle  it,  however,  it 
is  found  to  be  deeply  seated,  with  a  widely 
indurated  base  nearly  as  large  as  your  palm 
about  it.  It  is  flattened  at  its  top  and  has  a 
half  dozen  little  craters  from  which  pus  oozes 
and  bits  of  white  sloughs  protrude.  That  is 
a  large  carbuncle  beyond  any  mistake.  Both 
patients  are  debilitated  —  the  woman  from  a 
week's  pain  and  discomfort,  the  man  from 
nearly  three  weeks  of  a  similar  experience. 
Both  cases  are  uncomplicated,  so  far  as  we  can 
ascertain.  The  urines  are  free  from  sugar; 
both  patients  are  in  their  prime  and  of  previous 
good  health. 

If  you  have  a  properly  developed  curiosity 
you  will  ask,  What  is  a  carbuncle  and  wherein 
does  it  differ  from  a  boil? 

Billing's  Dictionary  defines  carbuncle  as 
"A  circumscribed  inflammation  of  skin  and 
subcutaneous  connective  tissue,  terminating 
in  a  slough."  More  than  that,  it  is  usually  a 
gangrenous  inflammation.  It  begins  on  the 
skin  as  does  a  boil,  but  it  spreads  much  deeper 


90  CLINICAL  TALKS 

and,  as  you  would  expect,  it  is  produced  by 
the  staphylococcus  pyogenes  albus  and  aureus. 
Do  not  confuse  this  process  with  anthrax,  as 
did  Billroth  and  the  older  pathologists.  An- 
thrax has  many  of  the  appearances  of  car- 
buncle, but  it  is  far  more  rapid,  it  has  a  wide 
reddened  zone  about  it,  it  has  not  the  charac- 
teristic elevated  flattened  surface,  it  is  nearly 
covered  with  a  gangrenous  eschar,  and  it  is 
caused  by  the  bacillus  anthracis. 

Our  characteristic  carbuncle  begins  then  as 
a  superficial  skin  inflammation  about  a  hair 
follicle  or  gland,  and  works  rapidly  downwards 
along  the  columnce  adiposcB  into  the  connective 
tissue:  there  it  spreads  rapidly,  involving  other 
columncB  and  other  glands,  pressing  upwards 
all  the  time,  elevating  the  overlying  skin,  find- 
ing numerous  points  of  exit  and  causing  exten- 
sive necrosis  of  the  connective  tissue  which 
it  involves.  It  is  usually  a  local  process,  but 
very  rarely  it  may  destroy  the  dense  aponeuro- 
sis of  the  underlying  muscles  and  extend  widely 
to  other  structures.  When  we  find  it  in  its 
usual  seat  on  the  back  of  the  neck  we  need 
not  fear  it  greatly,  for  tough  structures  limit 
it  below,  but  when  situated  in  regions  of  greater 
vascularity  and  more  delicate  composition, 
as  on  the  cheek  and  lip,  it  may  spread  rapidly, 
cause  serious  disfigurement,  and  even  threaten 
life. 


ON   MINOR  SURGERY  91 

Now,  gentlemen,  let  me  say  a  very  decided 
word  about  treatment  in  these  two  cases  before 
us.  There  is  but  one  method  for  you,  and  that 
method  is  nearly  always  sure  and  final, —  excise 
the  carbuncle.  Don't  dally  with  applications 
and  poultices  or  even  with  the  old-time  deep 
crucial  incisions.  They  mean  delay,  if  not 
extension,  of  the  process.  All  this  necrotic 
mass  in  each  case  has  got  to  come  out.  If  you 
poultice  or  incise  you  do  not  prevent  a  loss  of 
substance  —  substance  has  already  been  lost. 
It  is  far  better  thoroughly  to  excise  it  at  once. 

Take  as  our  best  example  the  man  with  the 
large  inflammation.  He  is  etherized,  for  the 
operation  is  a  considerable  one,  and  the  knife 
is  carried  cleanly  and  completely  around  the 
carbuncle,  outside  of  the  necrotic  area.  The 
blade  bites  down  to  the  underlying  fascia  and 
the  whole  sloughing  mass  is  dissected  out. 
The  bleeding  is  checked,  the  cavity  packed 
with  absorbent  gauze  and  the  wound  left  to 
granulate.  When  you  look  at  the  size  of  it 
you  will  exclaim  perhaps  that  here  is  a  need- 
less sacrifice  of  tissue  and  that  the  resulting 
scar  will  be  enormous.  You  will  be  surprised, 
in  the  course  of  two  or  three  weeks,  to  see  how 
the  sound  parts  have  come  together,  and  how 
trifling,  after  all,  will  be  the  evidence  left  of  the 
great  wound.  You  will  be  interested  also  to 
hear  the  patient's   own  account  of  himself  to- 


92  CLINICAL  TALKS 

morrow.  The  old  incisions  gave  but  little 
relief  at  the  time;  the  excisions  are  followed 
by  an  almost  immediate  reaction;  and  when 
next  this  man  comes  in  I  expect  to  hear  from 
him  that  he  has  passed  a  good  night,  has  eaten 
a  hearty  breakfast,  and  is  practically  free  from 
pain. 

The  woman  I  shall  treat  in  similar  fashion, 
but  the  resulting  wound  will  be  small  and  she 
will  experience  little  inconvenience  except  from 
the  loss  of  some  of  her  back  hair. 

Don't  coquette  with  a  carbuncle.  Cut  it  out 
as  you  would  a  cancer,  and  you  will  neVer 
regret  it. 


LECTURE    IX 

BUNIONS,  INGROWING  NAILS,   CORNS,   AND  WARTS 

Gentlemen  :  I  have  chosen  for  the  subject 
of  this  exercise  a  Httle  collection  of  seemingly 
trifling  lesions;  but  to  the  victims  they  are  not 
trifling  and  they  are  very  often  maltreated. 

Bunion  is  a  condition  so  frequently  associ- 
ated with  hallex  valgus  that  I  am  prompted 
to  call  your  attention  to  an  etymological  jest. 
Hallex  valgus,  an  extreme  deformity  and  out- 
ward displacement  of  the  great  toe,  was  for 
centuries  called  hullux  valgus.  As  such  you 
will  find  it  described  in  all  the  books  on  sur- 
gery. So  far  as  I  know,  Dr.  Robert  H.  M. 
Dawbarn,  of  New  York,  was  the  first  to  point 
out  the  error,  and  that  was  only  last  year.  The 
word  hallex  is  itself  archaic.  It  means  literally 
a  scoundrel;  and  you  shall  search  your  diction- 
aries to  find,  at  last,  "Allex  (hallex)  in  Isid. 
Gloss,  est  pollex  pedis." 

However  all  that  may  be,  bunion  is  a  good 
Greek  word.  A  bunion  is  an  inflamed  bursa, 
situated  usually  to  the  inner  side  of  the  meta- 
tarso-phalangeal  joint  of  the  great  toe,  and  if 

93 


94  CLINICAL  TALKS 

it  becomes  inflamed  it  makes  trouble.  Folk 
who  go  barefoot  or  wear  sandals  do  not  have 
bunions,  but  if  you  put  a  foot  into  an  ill-fitting 
boot  and  crowd  it  forward,  the  great  toe  will 
feel  the  impact  and  be  thrown  outward  across  the 
second  toe.  Sometimes  the  deformity  is  so 
extreme  that  the  great  toe  appears  to  be  at 
right  angles  to  the  axis  of  the  foot. 

When  this  deformity  takes  place,  as  you  can 
readily  see  in  the  man  here  under  inspection, 
the  toe  is  partially  dislocated  at  the  metatarsal 
joint,  and  upon  the  knuckle  so  formed  comes 
the  constant  pressure  of  the  side  of  the  boot. 
Here  lies  the  bursa  over  the  knuckle  and,  as  a 
result  of  the  pressure,  it  becomes  irritated, 
thickened,   and  inflamed. 

You  see  the  condition  is  a  compound  one, 
both  bone  and  bursa  being  involved.  In  this 
present  case  we  have  an  advanced  stage  of  the 
disease,  and  the  operation  which  I  shall  now 
do  will  illustrate  the  anatomy. 

I  make  a  sweeping  crescentic  incision  about 
the  dorsal  side  of  the  joint,  and  this  flap,  which 
is  four  inches  in  diameter,  I  turn  down  upon  the 
sole  of  the  foot.  The  exposed  bursal  sac  I 
next  open  and  dissect  out.  You  see  it  is  dis- 
tended with  a  flocculent  fluid,  and,  as  I  ex- 
pected, there  is  at  its  base  a  little  opening, 
which  leads  directly  into  the  joint.  This  has 
illustrated  for  us  a  point  I  intended  to  make 


ON   MINOR   SURGERY  95 

for  you,  namely,  that  you  are  never  safe  in 
operating  hastily  upon  a  bunion,  for  you  can- 
not always  tell  beforehand  whether  or  not  it 
may  communicate  with  the  joint.  Every 
surgeon  has  had  patients  come  to  him  from 
ignorant  "com  doctors,"  who  have  attempted 
to  pare  off  one  of  these  bunions,  with  a  result- 
ing opening  of  the  joint  and  a  severe  septic 
arthritis.  I  hope  it  is  needless  for  me  to  point 
out  to  you  that  our  operation  is  being  done 
under  the  strictest  precautions. 

Following  up  the  sinus,  I  lay  open  the  joint, 
of  which  the  ligaments  are  so  relaxed  from  the 
inflammation  that  their  function  is  destroyed, 
the  phalanx  being  in  a  state  of  subluxation. 
The  joint  cavity  contains  some  of  the  fluid 
that  we  saw  in  the  bursa  and  the  articulating 
surfaces  are  roughened  and  diseased;  in  other 
words,  we  have  shown  that  apparently  simple 
thing  called  a  bunion  to  be  an  extensive  dis- 
ease of  bursa,  joint  surface,  and  bone. 

There  is  no  possibility  of  success  from  palli- 
ative measures  in  this  case.  The  toe  cannot 
be  straightened  even  with  the  joint  laid  open. 
You  can  all  see  that  the  only  thing  to  do  is  to 
excise  the  end  of  the  metatarsal.  This  I  do, 
accordingly,  with  the  chain  saw,  and  find  that 
the  normal  line  of  the  great  toe  now  can  easily 
be  restored.  The  rest  of  the  treatment  follows 
naturally.     Bleeding  is  checked,  and  the  deep 


96  CLINICAL   TALKS 

parts  over  the  joint  are  closed  with  buried  cat- 
gut sutures,  in  order  that  the  false  joint  at 
which  we  aim  may  have  a  firm  lateral  support. 
Those  deep  buried  stitches  are  very  essential 
for  success.  The  skin  flap  is  then  stitched 
into  place  and  the  toe  is  held  in  its  new  straight 
position  by  a  light  tin  splint.  Over  all  is 
wrapped  firmly  a  wadding  and  mill-board 
dressing  to  the  knee,  and  the  patient  is  put  to 
bed.  By  the  end  of  the  week  I  shall  take  the 
dressing  down  and  hope  to  show  you  a  soundly 
healed  wound. 

This  case  was  an  extreme  one.  Hallex  val- 
gus has  been  its  conspicuous  feature,  but  here 
are  a  couple  of  simpler  cases  which  admit  of 
simpler  treatment.  Both  have  a  slight  out- 
ward bend  of  the  toe  and  an  inflamed  tender 
bursa  or  bunion  on  the  inner  side.  This  first 
patient,  the  woman,  has  a  toe  which  is  easily 
pulled  back  into  place.  I  shall  content  myself, 
for  the  present,  with  ordering  a  proper  pair  of 
broad,  square-heeled  laced  boots,  with  straight 
sole  on  the  inner  side.  Over  the  bunion  I  fit 
this  piece  of  felt,  cut  like  a  large  corn  plaster. 
That  will  protect  the  bursa  from  pressure,  and 
the  properly  made  boot  will  allow  the  slight 
deformity  of  the  toe  to  correct  itself.  These 
cases  are  frequently  associated  with  a  breaking- 
down  of  the  longitudinal  arch  of  the  foot  and  a 
consequent  flat-foot,  but  that  is  another  story. 


ON   MINOR  SURGERY  97 

Our  second  patient,  the  man,  has  a  hallex 
valgus  and  a  bunion  similar  to  the  woman's, 
but  the  toe  is  not  so  readily  pulled  into  place. 
For  him  I  have  had  a  hard  rubber  spoon  splint 
arranged.  The  bowl  of  the  spoon  has  a  handle 
at  either  end.  When  the  padded  bowl  is  laid 
over  the  bunion,  the  upper  handle  extends 
along  the  side  of  the  foot  and  the  lower  along 
the  toe.  Now  with  the  upper  handle  strapped 
into  place  I  pull  the  toe  inwards  toward  the 
lower  handle  and  so  correct  the  deformity. 
By  his  wearing  this  simple  apparatus  for  a  few 
weeks,  and  by  the  fitting  of  a  proper  boot,  I 
hope  permanently  to  correct  the  deformity. 

Another  crippling  affection  of  the  foot  is 
ingrowing  toenail.  This  also  is  a  disease  pe- 
culiar to  civilized  peoples  who  are  boot  wearers, 
and  is  not  seen  in  those  who  go  barefooted. 

Years  ago  an  old  army  surgeon  told  me  that 
he  had  no  trouble  with  ingrowing  toenails 
among  his  men  after  he  had  taught  them  how 
properly  to  trim  their  nails.  They  were  to 
cut  them  straight  across  instead  of  making  a 
rounded  corner.  I  have  found  that  simple  ma- 
noeuvre to  be  a  valuable  prophylactic  measure. 

The  common  seat  of  ingrowing  nail  is  on  the 
outer  side  of  the  great  toe.  As  with  bunion, 
it  is  due  to  ill-fitting  or  tight  boots.  This  young 
woman  illustrates  the  usual  story.  About 
a  year  ago  she  noticed  that  the  outer  side  of 


98  CLINICAL   TALKS 

her  toe  began  to  feel  sore.  It  was  red  and 
tender.  To  relieve  the  discomfort  she  trimmed 
the  nail  down  on  the  side.  That  answered 
well  enough  for  three  or  four  days,  but  by  the 
excision  of  that  strip  of  nail  the  pulp  was  given 
so  much  the  greater  latitude  for  bulging  in- 
wards. It  continued  to  encroach  upon  the 
nail,  became  irritated  and  eroded  by  the  rough 
nail  edge,  took  on  the  characteristics  of  a 
chronic  ulcer,  and  threw  out  exuberant  granu- 
lations, which  now  overlap  that  side.  You 
see  that  the  part  is  exquisitely  sensitive  to 
pressure,  and  that  a  little  pus  exudes  from 
under  the  granulations. 

Nothing  short  of  an  operation  is  to  be  done. 
Here  palliation  will  be  useless.  There  are  two 
or  three  operations  of  value.  I  will  tell  you 
of  two  of  them  and  then  do  a  third. 

Cotting's  operation  was  devised  by  a  well- 
known  Boston  doctor,  recently  dead.  It  con- 
sists of  passing  the  knife,  at  right  angles  to 
the  plane  of  the  nail,  into  the  pulp,  and  shaving 
off  the  whole  of  the  soft  parts  together  with 
a  narrow  sliver  of  nail  on  that  side  of  the  last 
joint  of  the  toe.  The  wound  is  left  to  granulate 
and  a  contracted  scar  instead  of  normal  pulp 
is  the  result.  Ingrowing  nail  cannot  occur 
again  there,  for  there  is  no  pulp  for  it  to  grow 
into.  The  operation  is  radical  and  effective, 
but  leaves  the  patient  with  a  sore  toe  for  weeks. 


ON    MINOR    SURGERY  99 

Then  there  is  a  similar  operation  which  con- 
sists of  cutting  out  a  "piece  of  pie"  as  it  were 
from  the  pulp  and  sewing  up  the  hole. 

In  this  patient's  case  I  prefer  to  do  a  good 
old  operation  which  has  the  advantage  of' 
simplicity.  The  toe  being  cocainized,  I  seize 
the  nail  deeply  and  firmly  with  a  strong  pair 
of  plying  forceps,  and  twist  it  out  entire;  then 
I  curette  off  the  granulations.  At  the  end  of 
several  months,  when  the  new  nail  has  grown 
out,  the  wounded  pulp  will  have  healed  and 
shrunk,  and  the  patient  will  then  be  as  though 
no  trouble  had  ever  been.  The  operation  is 
simple,  the  laceration  is  slight,  and  the  result- 
ing incapacity  of  very  brief  duration.  A  simple 
vaseline  and  gauze  dressing  is  all  that  is  re- 
quired. 

I  must  say  one  word,  and  an  important 
word  it  is,  about  palliation  in  the  incipient 
cases.  Palliation  means  properly  fitted  boots 
and  the  packing  of  cotton  under  the  nail.  If 
you  pack  skillfully  you  may  so  treat  a  pretty 
bad  case.  Few  men  do  so  pack.  Don't 
roughly  and  quickly  thrust  in  the  cotton. 
You  will  grievously  hurt  your  patient  and  you 
will  not  get  the  cotton  in.  With  the  patient's 
foot  on  your  knee,  take  a  strand  of  absorbent 
cotton,  lay  it  by  the  side  of  the  nail,  use  the 
back  of  a  narrow-bladed  knife,  and  gently  and 
patiently  with   a  succession   of  pushes  insinu- 


loo  CLINICAL    TALKS 

ate  the  cotton  under  the  edge.  The  patient 
will  experience  prompt  relief.  Repeat  the 
performance  once  a  week  until  you  establish 
a  cure. 

I  feel  almost  as  though  I  should  apologize 
to  you  for  saying  a  few  words  about  such 
trifling  things  as  corns  and  warts,  but  you  will 
be  asked  to  treat  them  and  you  may  be  at  your 
wits'  end  for  a  remedy. 

A  few  months  ago  a  young  fellow  from  the 
college  in  Cambridge  came  to  me  complaining 
that  he  had  run  several  splinters  of  wood  into 
his  foot  when  walking  barefooted  on  the  '  'float " 
at  the  boathouse.  He  had  pulled  out  two 
splinters  half  as  long  as  his  little  finger,  but 
a  third  had  been  healed  in  and  caused  him 
constant  pain  in  walking.  I  examined  the 
foot  and  could  distinctly  feel  the  foreign  body, 
as  large  as  a  medium  penknife  blade,  deep 
under  the  skin  at  the  base  of  the  second  toe. 
There  seemed  no  reason  to  doubt  the  presence 
there  of  a  splinter.  I  made  an  incision  deeply 
into  the  foot  and  went  down  for  nearly  an 
inch  through  a  stratum  of  tough  callous,  until 
I  reached  normal  tissue.  There  was  no  splinter 
there.  The  seeming  foreign  body  was  nothing 
but  a  great  callus,  which  I  excised,  and  so 
cured  the  lad  of  his  painful  foot,  —  but  I  had 
learned  my  lesson. 

This  callosity  was  of  the  nature  of  a  corn, 


ON    MINOR   SURGERY  loi 

which  is  made  up  of  a  circumscribed  excessive 
development  of  the  epidermis  and  of  a  central 
portion  or  core.  The  cqre  extends  quite  deeply 
into  the  tissues,  in  the  form  of  an  inverted 
cone,  the  base  being  directed  outwards,  appear- 
ing on  the  surface  as  a  rounded  area,  the  apex 
of  the  cone  resting  on  the  papillary  layer  of  the 
corium  and  causing  pain  when  pressed  upon. 
In  this  case  I  performed  a  radical  cure  in  the 
only  manner  which  is  possible,  namely,  by 
excision.  Nothing  else  will  do  it.  The  "corn 
doctors"  do  not  wish  to  cure.  Their  palliative 
measures  merely  relieve  pressure  for  a  time, 
but  the  patient  returns  repeatedly  for  further 
treatment. 

After  all,  few  patients  will  consent  to  so 
radical  a  measure  as  excision,  especially  with 
the  prospect,  if  they  are  not  careful,  of  a  fresh 
com  developing  about  the  site  of  the  scar.  So 
the  sufferer  comes  back  again  and  again  to 
parings  and  plasters,  and  will  continue  so  to  do 
as  long  as  boots  are  worn  and  com  doctors 
abound  in  the  land. 

Finally,  as  regards  warts,  there  are  several 
facts  which  you  should  bear  in  mind  about 
them.  There  are  four  principal  varieties:  The 
ordinary  homy  warts  of  children  (Verruca 
Vulgaris),  the  smooth  multiple  warts  on  the 
faces  of  old  persons  (Verruca  Senilis),  the  little 
wormlike  warts  which  we  see  hanging  from  the 


I02  CLINICAL  TALKS 

lids  (Verruca  Filiformis),  and  lastly,  venereal 
warts  (Verruca  Acuminata).  There  is  reason 
to  suppose  that  all  these  varieties  are  due  to 
some  infecting  organism,  though  this  is  not 
definitely  proven.  The  common  wart  of  chil- 
dren, seen  mostly  on  the  hands  and  fingers, 
may  appear  and  disappear  in  an  inexplicable 
manner.  It  is  composed  of  a  papilla  contain- 
ing a  vascular  loop;  this  is  covered  by  a  very 
much  thickened  horny  layer,  which  in  turn  is 
covered  by  an  hypertrophied  rete. 

The  little  boy  before  us  has  three  such  horny 
warts  on  his  fingers.  One  I  pare  down  with  a 
sharp  knife  and  touch  the  base  with  the  nitrate 
of  silver  stick;  the  second,  after  paring,  I  touch 
with  nitric  acid;  and  to  the  third  I  apply  this 
mixture  of  salicylic  acid,  the  important  ingre- 
dient of  most  of  the  patent  "wart  cures."  It 
contains  salicylic  acid,  5ss;  cannabis  indica, 
extract,  gr.  v;  flexible  collodion,  §7i.  This  is 
painted  on  the  wart  twice  a  day  for  five  days 
until  the  growth  becomes  necrotic.  The  finger 
is  then  soaked  for  fifteen  minutes  in  hot  water, 
when,  if  all  goes  well,  the  wart  will  drop  off. 

The  soft  flat  warts  of  elderly  persons  are 
permanent  and  are  not  especially  disfiguring, 
but  they  have  this  important  fact  connected 
with  them,  that  they  may  become  epitheliomata 
of  a  malignant  type.  The  patient  may  pick  at 
one  until  it  bleeds,  or  he  partially  dislodges  it, 


ON    MINOR    SURGERY  103 

when  he  finds  that  it  does  not  heal;  that  the 
Httle  ulcer,  so  formed,  spreads,  and  that  he  is 
concerned  with  a  troublesome  sore.  When  you 
see  such  an  affair,  cut  it  out  first,  and  then 
let  the  microscope  settle  its  exact  nature. 

Those  offensive  looking  filiform  warts  which 
you  see  hanging  from  the  lids  and  necks  of  your 
patients  may  be  very  simply  treated.  A  snip 
of  the  scissors  and  a  touch  with  the  lunar 
caustic  suffice  for  them. 

Then  there  are  those  venereal  warts  which 
are  seen  upon  the  genitals  and  are  due  to  sexual 
contact.  The  patients  are  often  much  fright- 
ened and  think  the  warts  are  indicative  of  seri- 
ous venereal  disease;  but  you  can  assure  them 
that  such  is  not  the  case.  The  growths  will 
disappear  if  washed  persistently  with  a  solu- 
tion of  tannin  in  alcohol,  one  drachm  to  three 
ounces;  the  wart  is  then  dried  and  dusted  with 
salicylic  acid. 

After  all  is  said,  however,  these  various 
forms  of  warts  seldom  make  trouble  and  their 
treatment  may  be  regarded  as  a  very  subordi- 
nate branch  of  cosmetic  surgery. 


LECTURE    X 


MASSAGE 


Gentlemen:  We  began  this  series  of  talks  by 
describing  the  value  and  effect  of  immobili- 
zation. 

In  this  final  exercise  I  propose  saying  some- 
thing of  the  value  of  motion  in  certain  inju- 
ries, of  motion  in  a  limited  sense  only,  —  mas- 
sage. That  is  a  subject  about  which  there 
has  long  been  much  misconception  among  sur- 
geons, and  even  to-day  this  useful  therapeutic 
measure  is  availed  of  less  than  it  deserves. 

Massage  is  no  new,  fanciful,  or  untried  thing. 
It  is  one  of  the  oldest  practices  in  medical  his- 
tory, and  is  referred  to  not  only  by  the  earliest 
writers  on  surgery,  but  by  poets  who  wrote 
long  before  medical  literature  began.  If  a 
boy  bumps  his  shin  he  rubs  it,  if  a  dog  bruises 
his  foot  he  licks  it.  There  you  have  nature 
prompting  to  a  primitive  massage,  the  uses  of 
which  have  been  elaborated  into  the  skillful 
manipulations  of  our  modern  experts. 

The  practice  was  in  bad  odor  for  long  in  this 

country  because  of  the  preposterous  claims  of 

104 


ON  MINOR  SURGERY  105 

its  ignorant  exponents  and  the  frequent  danger 
they  inflicted  upon  unsuitable  cases.  In  the 
course  of  years  all  that  was  changed:  educated 
men,  many  of  them  trained  in  Sweden  and 
France,  took  up  the  practice;  the  operators, 
both  men  and  women,  came  to  see  that  their 
work  was  as  assistants  to  surgeons  and  not  as 
their  rivals,  until  to-day  we  find  a  considerable 
number  of  such  competent  persons  in  every 
community.  Lately  there  has  developed  a 
curious  outcome  of  these  conditions.  A  so- 
called  "school  "  of  medicine  has  grown  up. 
Its  followers  apply  to  themselves  the  meaning- 
less term  "  Osteopathists  "  and  they  essay  on 
their  own  responsibility  various  forms  of  mas- 
sage. It  is  needless  to  say  that  these  ignorant 
persons  make  serious  errors  and  do  harm,  and 
doubtless  they  will  reach  the  limbo  where  thou- 
sands of  preceding  charlatans  lie  buried;  but 
meantime  they  bring  real  distress  upon  our 
honest  massage  friends,  whose  business  they  are 
cutting  into,  as  I  am  told. 

S,tudents  often  ask  me  how  they  can  learn 
about  the  methods  of  massage  and  whom  they 
shall  employ,  and  I  find  there  is  much  miscon- 
ception as  to  the  limits  of  its  usefulness.  A 
common  error  also  is  to  suppose  that  any  nurse 
or  orderly  can  learn  to  give  it  well  after  a  short 
course  of  instruction.  I  believe,  other  things 
being  equal,   that  the  best   masseuse  may  be 


io6  CLINICAL   TALKS 

developed  out  of  the  trained  nurse,  but  I  must 
tell  you  earnestly  that  the  best  masseuse  can 
remain  the  best  only  by  constant  practice. 
The  tactile  sense  required  is  quickly  lost  if 
allowed  to  rust,  and  the  strong,  lithe  muscles 
of  the  skilled  workman  become  inexpert  and 
feeble  when  long  unused.  Constant  practice 
is  as  essential  to  the  masseur  or  masseuse  as 
to  the  pianist,  the  artist,  or  the  football  player. 
The  professional  model  will  pose  immovable 
for  an  hour,  if  need  be,  before  the  "life  class  " 
in  the  studio;  but  I  am  told  of  the  strong  man 
Sandow  being  asked  to  pose  in  one  of  our  art 
schools  recently,  and  how,  after  enduring  the 
strain  for  ten  minutes,  he  was  forced  to  drop 
his  arm  in  exhaustion  and  chagrin.  The  aver- 
age nurse  can  give  excellent  rubbings  and  fric- 
tion when  required,  but  when  you  want  proper, 
expert  massage,  you  must  go  to  a  specialist 
who  does  nothing  else. 

I  have  no  intention  here  of  giving  you  a  dis- 
sertation on  massage,  nor  have  I  the  time  or 
requisite  knowledge;  but  I  do  wish  to  point 
out  to  you  and  to  illustrate  some  of  the  condi- 
tions in  which  massage  is  of  value  in  surgery. 
One  of  the  commonest  of  injuries  —  an  injury 
for  long  a  reproach  to  our  art  —  is  sprained 
ankle.  It  was  the  practice  up  to  ten  years 
ago  —  and  the  practice  is  still  followed  by  the 
indifferent  —  to     immobilize     sprained     joints. 


ON    MINOR    SURGERY  107 

The  result  was  that  patients  so  treated  were 
tied  to  crutches  for  weeks  or  months,  the  time 
depending  on  the  severity  of  the  sprain, —  and 
after  the  splint  and  crutches  were  thrown  aside 
they  limped  about  as  cripples  for  an  indefinite 
period.  It  used  to  be  a  common  saying  that 
a  man  must  expect  to  feel  his  sprain  occasion- 
ally for  the  rest  of  his  life,  even  if  he  be  not 
left  with  a  joint  permanently  stiff  and  painful. 
That  such  were  the  results  sometimes  seen, 
every  surgeon  of  fifteen  years'  experience  can 
tell  you.  A  recent  writer  has  said:  "Suppos- 
ing a  prize  of  ten  thousand  dollars  were  offered 
for  the  quickest  way  to  make  a  well  joint  stiff, 
what  more  effectual  means  could  be  resorted 
to  than  first  to  give  it  a  wrench  or  sprain,  and 
then  do  it  up  in  a  fixed  dressing  so  that  the 
resulting  imflammation  would  have  an  oppor- 
tunity of  producing  adhesions  of  the  parts?  "^ 

The  man  whom  I  now  show  you  slipped  from 
the  curbstone  and  * '  turned  his  ankle  ' '  while 
running  for  a  street  car  yesterday,  and  on 
rising  found  himself  unable  to  stand  or  walk 
without  agony.  He  was  carried  home  and 
shortly  after  the  removal  of  his  boot  found 
that  his  ankle  was  swollen,  discolored,  and  very 
painful.  This  morning  he  came  here  on  crutches 
for  treatment. 

The  one  important  lesion  which  we  have  to 

1  "A  Treatise  on  Massage,"  by  Douglas  Graham,  M.D. 


io8  CLINICAL    TALKS 

distinguish  from  simple  sprain  of  the  ankle  is 
Pott's  fracture  —  which  you  know  to  be  a 
fracture  of  the  fibula  just  above  the  malleolus, 
with  eversion  of  the  foot  and  rupture  of  the 
internal  lateral  ligament.  Palpation  in  this 
case  shows  us  no  such  fracture,  and  the  x-ray 
plate  which  I  have  had  taken  demonstrates 
sound  bones   of  the   leg   and   tarsus. 

But  what  do  you  see  and  feel?  The  foot  is 
swollen  and  boggy,  especially  over  the  internal 
malleolus,  and  the  skin  is  stained  a  pale  yellow 
from  extravasated  blood  and  serum.  Doubt- 
less the  man  violently  wrenched  his  foot,  bruis- 
ing the  synovia  of  the  joint  surfaces,  stretch- 
ing and  bruising  the  tendons  and  tendon 
sheaths,  and  tearing  a  few  of  the  fibers  of  the 
lateral  ligament.  As  a  result  there  has  been 
a  certain  amount  of  escape  of  blood  from  the 
damaged  soft  parts  and  a  serous  exudate, 
stimulated  by  the  increased  flow  of  blood  to 
the  part,  in  nature's  primary  attempt  to  repair 
damages.  The  exudate  has  infiltrated  the  tis- 
sues, with  this  resulting  discoloration.  As  time 
goes  on  the  exudate  will  settle  out  more  and 
more  towards  the  surface  and  the  staining  of 
the  skin  will  become  darker,  until  by  the  end 
of  four  or  five  days  you  shall  see  the  skin  over 
the  dorsum  deeply  pigmented  and  the  ecchy- 
mosis,  following  the  tendons  and  muscle  inter- 
spaces, appearing  well  up  on  the  calf. 


ON    MINOR   SURGERY  109 

Here  then  is  our  problem:  Shall  we  leave  all 
this  exudate  to  remain  quiet  and  to  organize 
and  cause  adhesions  of  tendon  and  joint  sur- 
faces, thus  impeding  the  circulation  and  im- 
pairing the  nutrition  of  the  parts?  or  shall  we 
endeavor  to  remove  it  and,  by  stimulating  the 
circulation,  promote  repair  and  the  reestablish- 
ment  of  function?  I  have  told  you  of  the 
results  of  the  former  practice.  The  masseur 
will  now  demonstrate  the  alternative. 

The  patient's  leg  is  bared  to  the  hip,  so  that 
there  shall  be  nothing  to  constrict  or  impede 
the  circulation,  as  he  lies  upon  the  examining 
table.  You  see  how  the  operator  begins  his 
manipulations  gently  and  at  a  distance  from 
the  joint.  I  think  it  a  pretty  sight  to  watch 
the  work  of  an  expert.  He  kneads  and  rolls 
the  muscles  of  the  calf,  urging  always  the  return 
flow  of  lymph  and  venous  blood  away  from  the 
ankle.  Shortly  the  circulation  begins  to  im- 
prove. The  puffy,  indurated  *feel"  of  the 
leg  is  less  pronounced  and  the  pain  diminishes 
in  the  area  worked  upon  as  the  exudate  is 
forced  along  into  the  lymph  spaces  where  the 
stimulated  current  is  beginning  to  take  it  up 
and  carry  it  on  into  the  general  circulation. 
Gradually  the  manipulations  are  carried  into  the 
region  of  the  damaged  joint;  the  toes,  the  sole 
and  the  dorsum  of  the  foot  receive  their  share 
of  attention,  until  as  you  see,  we  are  now  actu- 


no  CLINICAL  TALKS 

ally  rubbing  and  kneading  upon  the  joint 
itself,  where  half  an  hour  ago  the  pain  and 
tenderness  were  so  great  that  the  patient  could 
scarcely  endure  the  weight  of  my  examining 
hand.  Having  thus  kneaded  and  stimulated  the 
parts,  and  diminished  the  pressure  so  that 
the  painful  distention  is  no  longer  so  apparent, 
the  foot  is  put  up  in  a  carefully  applied  flannel 
bandage,  from  toes  to  knee,  and  the  patient 
allowed  to  walk  with  the  aid  of  his  crutches. 
You  see  he  finds  that  he  can  now  bear  some 
weight  upon  his  lame  foot.  This  treatment 
will  be  repeated  daily  for  a  week  or  ten  days, 
by  the  end  of  which  time  I  hope  to  be  able  to 
discharge  him  practically  well. 

You  must  bear  in  mind  that  complications 
may  be  looked  for  in  these  injuries  and  may 
call  for  treatment.  One  of  the  commonest  of 
them  is  acute  articular  rheumatism,  in  those 
persons  who  are  given  to  that  affliction;  for 
you  must  remember  that  rheumatism,  like 
tuberculosis,  is  wont  to  attack  the  parts  weak- 
ened for  resistance.  I  always  bear  this  possi- 
bility of  rheumatism  in  mind,  and  during  the 
convalescence  from  sprains  I  forbid  alcohol 
and  look  carefully  to  the  patients'  general  con- 
dition, especially  to  his  secretions.  That  ques- 
tion of  tuberculosis  is  an  important  one  also. 
We  all  know  how  frequently  the  development 
of  a  localized  tuberculosis  may  be  traced  appar- 


ON   MINOR   SURGERY  iii 

ently  to  some  trauma,  and  I  call  your  attention 
to  the  fact  that  a  sprained  joint,  which  remains 
unsound  for  long,  especially  when  treated  by  the 
old-fashioned  immobilization,  gives  us  excellent 
conditions  for  the  subsequent  development  of  a 
chronic  infection.  You  can  well  imagine  how 
such  a  joint,  illy  nourished,  anemic,  with  an 
impeded  blood  and  lymph  current,  partially 
anchylosed  and  associated  naturally  with  flabby, 
atrophied  muscles,  presents  an  admirable  seat 
of  lodgment  for  tubercle  bacilli.  The  organ- 
isms, as  you  know,  begin  their  destructive  proc- 
ess first  in  the  epiphyses  of  the  bones,  and  from 
there  proceed  to  involve  the  joint  surfaces; 
so  here  again  we  find  further  reason  in  the  case 
of  fresh  sprains  for  expediating  a  healing. 

Another  lesion  which  furnishes  us  with  an 
opportunity  for  brilliant  results  from  massage 
is  dislocation.  I  have  told  you  in  a  former 
talk  of  the  value  of  massage  in  fractures,  but 
in  dislocation  its  use  is  even  more  satisfactory. 

Here  is  a  typical  case  for  us  —  a  man  with 
a  subcoracoid  dislocation  of  the  humerus.  He 
is  a  stout  man  and  the  diagnosis  is  not  imme- 
diately apparent.  You  do  not  readily  make  out 
the  flattening  of  the  deltoid  and  outward  trend 
of  the  humerus  away  from  the  side,  but  if  you 
will  practise  bimanual  palpation  of  the  axilla 
on  both  shoulders  you  cannot  fail  to  establish 
the   diagnovsis.     On   the   sound   side,   with   one 


112  CLINICAL  TALKS 

finger  below  the  coracoid  process  and  the  other 
high  in  the  axilla,  you  can  almost  make  the 
fingers  touch  through  the  pect oralis  major, 
which  alone  intervenes.  Try  the  same  on  the 
affected  side  and  you  will  be  surprised  to  find 
that,  push  as  hard  as  you  will,  a  great  interval 
still  separates  your  fingers.  That  interval  is 
occupied  by  the  head  of  the  humerus,  dislo- 
cated under  the  coracoid.  The  patient  will  be 
etherized  at  once  and  the  dislocation  reduced. 
To-morrow  he  will  return  for  massage.  F^r 
the  first  week  this  will  be  given  for  twenty 
minutes  daily  while  the  arm  is  supported 
motionless  in  a  sling.  The  same  method  in 
general  that  we  have  seen  employed  on  the 
ankle  will  be  followed.  Pain  will  quickly  be 
relieved  and  the  nutrition  of  the  parts  improved. 
After  a  week,  gentle  passive  and  active  move- 
ments will  be  begun,  and  by  the  end  of  three 
weeks  of  such  practice  we  hope  to  have  estab- 
lished a  cure. 

That  matter  of  combining  movements  with 
massage  in  these  cases  is  an  important  one. 
You  shall  find,  for  instance,  in  old  shoulder 
dislocations  which  have  been  reduced  and  sub- 
sequently immobilized  for  a  long  time,  accord- 
ing to  the_ancient  practice,  wasting,  weakness, 
and  stiffness  resulting.  If  then  you  attempt 
by  massage  to  restore  the  parts  you  will  succeed 
very  likely  in  rendering  the  joint  supple,  but 


ON   MINOR   SURGERY  113 

you  will  not  increase  materially  the  size  and 
power  of  the  muscles.  Faradism  will  then 
help,  by  causing  muscular  contractions,  but 
you  can  accomplish  the  same  thing  by  active 
and  passive  movements.  So  remember  that 
in  all  these  joint  injuries  your  massage  must 
be  supplemented  by  movements,  in  order  prop- 
erly to  restore  normal  function. 

There  are  numerous  other  conditions  in  which 
massage  is  of  the  greatest  value,  especially 
in  contractures  and  deformities  left  by  old 
injuries  or  inflammatory  processes  which  have 
subsided.  In  those  cases  patience  and  faith 
are  often  required  for  a  long  time,  but  the  final 
results  usually  justify  the  treatment.  As  to 
the  use  of  general  massage  after  major  opera- 
tions and  prostrating  surgical  affections,  there 
is  no  time  to  speak  except  to  say  that  I  have 
employed  it  commonly  in  such  conditions,  and 
with  the  most  gratifying  results,  for  the  secre- 
tions are  thereby  increased,  the  circulation 
improved,  the  appetite,  sleep,  and  mental  state 
stimulated,  and  the  convalescence,  after  the 
patient's  getting  out  of  bed,  materially  and 
happily  abridged. 

Naturally  you  will  ask  me.  In  what  condi- 
tions is  massage  contraindicated?  That  is  a 
question  which  it  is  difficult  to  answer  in  gen- 
eral terms,  but  I  may  safely  say  this  —  that 
wherever  an    active    tissue-destroying    process 


114  CLINICAL    TALKS 

is  established,  such  as  cancer  or  tuberculo- 
sis, there  local  massage  is  very  likely  to  do 
harm. 

I  am.  perfectly  well  aware,  after  what  I  have 
said,  that  you  may  take  to  prescribing  massage 
freely  for  lesions  of  all  sorts  and  conditions, 
and  that  you  are  likely  to  be  grievously  disap- 
pointed at  times.  Nothing  but  experience 
will  remedy  such  trials,  for  you  must  learn  to 
select  your  cases  and  beyond  all  else  you  must 
know  that  proper  massage  is  not  to  be  had  for 
the  asking.  Bad  massage  is  worse  than  no 
massage  at  all.  Good  massage  is  not  always 
easy  to  find.  This  community  of  ours  is 
crowded  with  the  spurious  article.  Make  sure 
always  that  you  have  secured  the  best,  and 
you  will  have  provided  yourselves  with  one 
of  the  most  valuable  of  therapeutic  meas- 
ures. 

In  concluding  this  little  series  of  talks, 
gentlemen,  let  me  remind  you  that  good  sur- 
gery, like  good  literature,  has  certain  old,  salient, 
well-established  characteristics  and  that  it  is 
at  the  same  time  a  progressive  science.  We 
in  our  generation  have  contributed  asepsis  to 
the  art  of  surgery,  and  thereby  we  have  made 
possible  an  enormous  widening  of  the  safety 
zone  of  the  operative  field.  But,  after  all, 
sound  judgment,  the  skill  of  a  handicraftsman, 
accurate   knowledge  of  anatomy,   appreciation 


ON   MINOR    SURGERY  115 

of  the  nature  of  physiological  processes,  and  a 
constant  regard  for  the  comfort  of  the  patient 
are  essential  if  you  are  to  succeed  in  this  most 
difficult,  nerve-racking,  exhausting,  and  fasci- 
nating branch  of  our  profession. 


Date  Due 

« 

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'  /     -l   "^ 

' 

• 

^ 

RD31 


M912 


COLU.BiAUNWERS.VLlBRARlES(hs,.stx) 
"2002109387 


r?,MMM:. 


